MAAS-MI Prep

1Chapter 1. Exploring Reasons for Encounter

• 1.1Theme 1 — Opening the consultation

  The first sixty seconds decide what the rest of the consultation is about. These exercises practise the move from a closed or leading opening to one that invites the patient’s full agenda.

  For the skills behind these exercises, see MAAS items 1.1 and A.2 on this website, and Chapter 1 of the handbook (§ Opening the Consultation) for the reasoning.

  1. Recognition — Openings that leave room

  Goal

  Recognise which opening invites the patient to shape the agenda.

  Task

  A patient enters your consultation. Their chart shows they saw a colleague two weeks ago for headaches. Which opening gives the patient the most room to say what is actually on their mind today?

  • A) “I see you were here for headaches — still the same problem today?”
  • B) “What would you like to discuss today?”
  • C) “Are you here about the headaches, or something new?”
  • D) “Is it the headaches again?”

  Reveal answer

  B is the most open. A frames the visit around what you already know — it closes the space for anything else. B leaves the agenda entirely to the patient; notice how it invites them to shape what comes next. C offers two options but treats them as alternatives — some patients arrive with something on neither list. D assumes the reason; if you are right it saves a step, if you are wrong you have silently shifted their agenda. (MAAS 1.1)

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  2. Reformulation — Opening an open question

  Goal

  Turn a closed opening into one that gives the patient more room.

  Task

  Rewrite this opening so the patient has space to shape what comes next:

  “Are you here about the cough?”

  Write your version down before revealing the exemplars.

  Reveal exemplars

  Exemplars:

  • “What would you like to discuss today?”
  • “What brings you in today?”
  • “Tell me what is on your mind.”
  • “How can I help you today?”

  You have moved from a yes/no opening toward something more open — that is the core move. Compare your version with the exemplars: notice that none of them name a specific complaint. The opening is the moment to learn what the patient wants, not to confirm what you expect. Read yours aloud alongside one of the exemplars — which feels closer to your consulting voice? (MAAS 1.1)

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  3. Spot-the-issue — What did the physician skip?

  Goal

  Notice when an item is missed, using a short transcript.

  Task

  Read this opening. Which MAAS item(s) has the physician skipped?

  Physician: Good morning. Your blood pressure was a bit high last visit — did you start the medication?
  Patient: Yes, but—
  Physician: Any side effects?
  Patient: A little dizziness in the mornings. But actually, I wanted to—
  Physician: Let’s measure your blood pressure first.

  Reveal answer

  1.1 and A.2 are both missed. The physician assumed the visit was about blood-pressure follow-up. Notice the patient tried twice to bring something else: “Yes, but—” and “actually, I wanted to—”. Both openings were closed off. A.2 (offering an agenda) would have surfaced what else is on the patient’s mind before the BP conversation starts. (Feedback Index: Structure and Sequence)

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  4. Apply to case — Chest pain opening

  Goal

  Use an open opening in a specific complaint.

  Task

  A 48-year-old man walks into your consultation room. He looks tense. You know from the intake note he is here about chest pain. Before he starts describing the pain, how would you open the consultation? Write down the exact words you would use.

  Reveal exemplars

  Exemplars:

  • “Tell me what brings you in today.”
  • “I can see you are here about chest pain — what would you like me to know first?”
  • “Before we get into the details, is there something else on your mind today?”

  Compare your opening with the exemplars. Notice that even when the complaint is already on the chart, the exemplars pause before going straight to pain — they leave room for the patient to name what matters most. Chest pain often travels with fear, and sometimes with another symptom the patient was saving for later. Your opening may be fine as-is, or you may want to borrow a phrase from the exemplars. (MAAS 1.1)

• 1.2Theme 2 — Understanding the person

  Once the agenda is open, the next move is to learn who sits in front of you — what they feel, why they came now, what they believe is causing this, and who in their life has been part of the story.

  For the skills behind these exercises, see MAAS items 1.2, 1.3, 1.4, and 1.5 on this website, and Chapter 1 of the handbook (§ Understanding the Person) for the reasoning.

  1. Recognition — Which question invites the emotional story?

  Goal

  Recognise the question that opens space for the patient’s emotional experience.

  Task

  A patient has just described six months of fatigue. Which of these would you ask next if you wanted them to speak about the emotional impact?

  • A) “Are you depressed?”
  • B) “How is this fatigue affecting you?”
  • C) “Do you feel worried about it?”
  • D) “Is your mood OK?”

  Reveal answer

  B is the most open. A and D ask closed yes/no questions about a specific state; the patient can say “no” and the door closes. C names one emotion and asks for confirmation — easier to deflect than to engage. B invites the patient to describe their experience without naming it first. Their own words will tell you which emotion is in play. (MAAS 1.2)

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  2. Reformulation — From a closed probe to an open one

  Goal

  Rewrite a leading closed question into one that opens space for the patient’s own view.

  Task

  Rewrite this question so the patient can tell you what they actually think:

  “You’re not worried it’s something serious, are you?”

  Reveal exemplars

  Exemplars:

  • “What have you been thinking this might be?”
  • “What’s going through your mind about this?”
  • “Is there anything in particular you were worried it could be?”

  The original carries an answer inside the question — a polite way of telling the patient not to worry. The exemplars do the opposite: they ask the patient what they have been thinking, which is often where the real concern lives. You cannot reassure someone whose worry you have not heard. (MAAS 1.2, 1.4)

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  3. Apply to case — Why now?

  Goal

  Ask the “why now?” question in a case where the complaint has existed for a long time.

  Task

  A 55-year-old woman has had low back pain for more than a year. She is only now coming to see you. How would you ask why she decided to come today, rather than weeks or months ago? Write down your exact question.

  Reveal exemplars

  Exemplars:

  • “What made you decide to come in today?”
  • “You’ve had this for a while — what changed that brought you in this week?”
  • “Why today rather than last month?”

  Compare your version with the exemplars. Each one assumes a trigger without demanding one. Chronic complaints usually have a reason for now — a new symptom, a worry, something a family member said, a planned trip. Finding the reason for now often uncovers the real concern. (MAAS 1.3)

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  4. Spot-the-issue — The social world

  Goal

  Notice when the patient’s relationships and social context have been skipped.

  Task

  Read this excerpt. The physician has explored the patient’s fatigue thoroughly. What item has been overlooked?

  Physician: So the fatigue has been worse since January, worst in the afternoons, and doesn’t improve with sleep. Any fevers, weight change, or night sweats?
  Patient: No to all of those.
  Physician: Right. Let’s order some blood tests and go from there.

  Reveal answer

  1.5 — the physician has not asked who in the patient’s life knows about this or how it has been discussed. Fatigue rarely exists alone: it reshapes home, work, partnership, caregiving. Asking “Have you talked to anyone about this?” often surfaces the fear or the expectation that set the visit in motion. (Feedback Index: Emotional Attunement)

• 1.3Theme 3 — Understanding wants and actions

  By this point you know what the patient feels and believes. Next: what they came to ask for, and what they have already tried. Patients often know what they want before they arrive — sometimes a specific medicine, sometimes only reassurance. And they rarely arrive without having tried something.

  For the skills behind these exercises, see MAAS items 1.6 and 1.7 on this website, and Chapter 1 of the handbook (§ Understanding Wants and Actions) for the reasoning.

  1. Recognition — Which question asks what the patient wants?

  Goal

  Recognise the question that surfaces what the patient is actually hoping for.

  Task

  A patient has described a persistent cough. Which follow-up gets at what they are hoping you will do?

  • A) “Do you want antibiotics?”
  • B) “What were you hoping we could do about this?”
  • C) “Shall we order a chest X-ray?”
  • D) “Is there something specific worrying you?”

  Reveal answer

  B is the most open. A and C offer a single option and treat it as the patient’s implied wish; if they wanted something else you will not hear it. D asks about worry, which is valuable but different — some patients come for reassurance, others for a prescription, others for a referral. B hands the question over without naming an answer first. (MAAS 1.6)

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  2. Reformulation — From reassurance to inquiry

  Goal

  Rewrite a reassuring statement into a question about what the patient wants.

  Task

  Rewrite this so it asks rather than reassures:

  “It’s probably nothing serious — no need to worry.”

  Reveal exemplars

  Exemplars:

  • “What were you hoping we could do today?”
  • “Is there a particular outcome you had in mind?”
  • “What kind of help would feel most useful right now?”

  The original closes the topic before hearing what the patient wanted to raise. The exemplars open it — they let the patient tell you whether they came for a diagnosis, reassurance, a sick note, a referral, or something else. You cannot match the help to the need without asking. (MAAS 1.6)

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  3. Apply to case — Self-help in chronic back pain

  Goal

  Ask about what the patient has already tried themselves.

  Task

  A 45-year-old man has had low back pain for six months. He has not seen anyone about it until now. What question would you ask to find out what he has tried himself? Write it down before revealing the exemplars.

  Reveal exemplars

  Exemplars:

  • “What have you tried so far to manage this?”
  • “Have you changed anything in your daily life because of this — or tried something that helps?”
  • “Before coming in, what did you do when the pain was bad?”

  Compare your version with the exemplars. Notice that all three assume the patient has tried something — most have. What they have tried tells you what has not worked, what they believe helps, and often what they hope you will add. A patient who has been taking daily paracetamol for six months is sending a different signal from one who has been doing stretches. (MAAS 1.7)

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  4. Spot-the-issue — The help that wasn’t asked about

  Goal

  Notice when the physician has decided what the patient wants without asking.

  Task

  Read this exchange. What item has the physician skipped?

  Patient: I’ve had this rash on my forearms for about two weeks. It itches.
  Physician: Right. Let me have a look. Yes — this looks like contact dermatitis. I’ll prescribe a steroid cream. Apply it twice a day for a week.
  Patient: OK. Thanks.

  Reveal answer

  1.6 has been skipped. The physician diagnosed and prescribed without asking what the patient wanted. Perhaps the patient came for a cream — or perhaps they came worried it was something worse, wanted to know what was causing it, or were hoping for a dermatology referral. Asking “What were you hoping we could do about it?” takes a few seconds and often changes the shape of the consultation. (Feedback Index: Patient Agenda)

• 1.4Theme 4 — Impact assessment

  The last theme of Reasons for Encounter anchors the complaint in the patient’s life: what has it cost them in work, sleep, relationships, mood, or mobility? This is the dimension that determines how much the patient will push through, tolerate, or change to get better.

  For the skills behind these exercises, see MAAS item 1.8 on this website, and Chapter 1 of the handbook (§ Impact Assessment) for the reasoning.

  1. Recognition — The question that reaches daily life

  Goal

  Recognise the question that gets at how the complaint changes what the patient actually does.

  Task

  A patient has described six weeks of knee pain. Which question best captures how this is affecting them day-to-day?

  • A) “Does it hurt a lot?”
  • B) “How is this affecting your daily life?”
  • C) “Is it affecting your sleep?”
  • D) “Can you still work?”

  Reveal answer

  B opens the widest picture. A asks about intensity, not impact. C and D ask about specific domains — useful as follow-ups, but each closes off the others. B invites the patient to name the domain that matters most to them: for one person it is sleep, for another it is the walk to the bus stop, for another it is being unable to pick up their child. (MAAS 1.8)

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  2. Reformulation — From abstract to concrete impact

  Goal

  Rewrite a vague impact question into one that asks for a specific change.

  Task

  Rewrite this so the patient describes a concrete change, not a rating:

  “How bad is this for you overall?”

  Reveal exemplars

  Exemplars:

  • “What has this stopped you from doing that you would normally do?”
  • “Is there something in your daily life that has changed because of this?”
  • “Give me an example of a day this week that was affected.”

  The original invites a single global judgement — “pretty bad, I guess.” The exemplars ask the patient to name a concrete change, and concrete changes are diagnostic: a cough that keeps someone out of their choir matters differently from a cough that stops them sleeping. Specific impact signals severity better than a general rating. (MAAS 1.8)

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  3. Apply to case — Migraine and daily function

  Goal

  Ask about the full impact of a migraine on a patient’s week.

  Task

  A 28-year-old teacher has had migraines about twice a month for the past year. What question would you ask to build a picture of how the migraines are shaping her life? Write your question down before revealing the exemplars.

  Reveal exemplars

  Exemplars:

  • “On a migraine day, what happens to the rest of your day?”
  • “How is this showing up in your work and outside of work?”
  • “Is there anything you have stopped doing, or started avoiding, because of these?”

  Compare your version with the exemplars. Each one nudges toward specifics — a day, a behaviour, a thing that is no longer being done. With a schoolteacher, the answer you get will tell you whether this is a quality-of-life problem, a job-security problem, or a relationship problem; three very different treatment conversations follow. (MAAS 1.8)

2Chapter 2. History-taking

• 2.1Theme 1 — The complaint heuristic

  The first heuristic asks four questions about the complaint itself: what it feels like, how intense it is, where it sits, and whether it moves. Together they anchor the diagnostic picture.

  For the skills behind these exercises, see MAAS items 2.1, 2.2, 2.3, and 2.4 on this website, and Chapter 2 of the handbook (§ The Complaint Heuristic) for the reasoning.

  1. Recognition — Open vs. closed questions about pain

  Goal

  Recognise the question that lets the patient describe the pain in their own words.

  Task

  The patient has said their chest hurts. Which follow-up question gives you the richest picture of the pain?

  • A) “Is it sharp or dull?”
  • B) “Is it a pressure kind of pain?”
  • C) “Can you describe what the pain feels like?”
  • D) “Does it burn?”

  Reveal answer

  C opens the widest door. A, B, and D each hand the patient a single descriptor; most patients will reach for the nearest one on offer rather than the word that fits best. C lets the patient choose their own language — “pressure,” “tearing,” “heavy,” “like an iron band” — and the language they choose carries diagnostic weight. (MAAS 2.1)

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  2. Reformulation — From a leading question to a neutral one

  Goal

  Rewrite a question so it stops suggesting an answer.

  Task

  Rewrite this question so it no longer points the patient toward a particular answer:

  “So it’s a crushing, central chest pain, isn’t it?”

  Reveal exemplars

  Exemplars:

  • “Can you describe what the pain is like, in your own words?”
  • “What kind of pain is it?”
  • “How would you describe it?”

  The original asks the patient to confirm a textbook picture. If they are tired, polite, or uncertain they will say yes — and you will not know whether the answer came from them or from your question. The exemplars hand the description back to the patient. You may still hear “crushing and central,” but now you will know the words are theirs. (MAAS 2.1)

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  3. Apply to case — Chest pain, all four complaint questions

  Goal

  Ask the four complaint-heuristic questions in a real case.

  Task

  The 48-year-old man from Chapter 1 has just said his chest has been hurting since this morning. Write down one question you would ask for each of the four complaint dimensions:

  • Nature (what it feels like): _____
  • Intensity (how bad): _____
  • Localisation (where): _____
  • Radiation (where it moves): _____

  Reveal exemplars

  Exemplars:

  • Nature: “Can you describe what it feels like?”
  • Intensity: “How bad is it — how is it affecting what you can do?”
  • Localisation: “Can you show me where exactly?”
  • Radiation: “Does it stay in one place, or does it travel anywhere?”

  Compare your four questions with the exemplars. Notice that each exemplar leaves room for the patient to surprise you — pain that began in the chest and moved to the jaw or arm is a diagnostic signal you will miss if you never ask about movement. All four together build the picture that the next heuristics will refine. (MAAS 2.1–2.4 · H1)

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  4. Ordering — A natural flow

  Goal

  Arrange the four complaint questions in an order that feels natural in conversation.

  Task

  A patient has just said their back hurts. Put these four questions in the order you would ask them:

  • “Does it move anywhere — down a leg, up into your neck?”
  • “Where exactly is the pain?”
  • “Can you describe what it feels like?”
  • “How bad is it, on a scale of any sort you’d use?”

  Reveal answer

  A natural sequence is Nature → Localisation → Intensity → Radiation — describe, then place, then weigh, then follow. Other orders can work. What matters is that the patient experiences one question naturally leading into the next, rather than four disconnected interrogations. Reading them aloud in your chosen order will tell you whether the flow feels like conversation. (MAAS H1)

• 2.2Theme 2 — The time-intensity heuristic

  The second heuristic places the complaint in time — its history and its daily pattern. A symptom read across time tells a different story from the same symptom described at a moment.

  For the skills behind these exercises, see MAAS items 2.5 and 2.6 on this website, and Chapter 2 of the handbook (§ The Time-Intensity Heuristic) for the reasoning.

  1. Recognition — Time questions that reveal pattern

  Goal

  Recognise the question that asks for a timeline, not a point.

  Task

  A patient says they have had stomach pain “for a while.” Which follow-up gives you the most useful temporal picture?

  • A) “How long exactly?”
  • B) “Weeks or months?”
  • C) “Can you tell me the story of this — when it started, how it has changed?”
  • D) “Was there a day it began?”

  Reveal answer

  C asks for a trajectory. A and B ask for a single number; you will get one, but it will not tell you whether things are better, worse, or steady. D anchors the start but stops there. C invites the shape of the episode — start, course, changes — and that shape is usually more diagnostic than the duration alone. (MAAS 2.5)

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  2. Apply to case — The headache timeline

  Goal

  Ask for both the history over time and the daily pattern.

  Task

  A 35-year-old woman presents with recurrent headaches. Write down two questions:

  • One that asks for the history over time (how the problem has unfolded over weeks or months): _____
  • One that asks for the daily pattern (when in the day, triggered by what): _____

  Reveal exemplars

  Exemplars:

  • History over time: “When did these headaches begin, and how have they changed since then?”
  • Daily pattern: “On a day when you have one — when does it come on, how long does it last, what makes it worse or better during the day?”

  Compare your two questions with the exemplars. Notice that both ask the patient to describe movement through time — across months for the first, across hours for the second. Migraine, tension headache, and medication-overuse headache each have distinct patterns at these two scales. (MAAS 2.5, 2.6)

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  3. Spot-the-issue — The temporal picture is missing

  Goal

  Notice when a full complaint description has been collected without placing it in time.

  Task

  Read this exchange. The physician has thoroughly explored the complaint itself. What is missing?

  Patient: The pain is in my right upper belly. It’s a dull, heavy pain, maybe a six out of ten. It doesn’t move.
  Physician: Any nausea, fever, or yellowing of your skin or eyes?
  Patient: No.
  Physician: OK, let’s examine you.

  Reveal answer

  The time-intensity heuristic (H2) is missing entirely. We know what the pain feels like, how bad it is, and where it sits — but not whether it started this morning, this week, or last year; whether it is steady, worsening, or intermittent; whether it comes after meals or at night. The differential between gallstone colic, chronic cholecystitis, and something more sinister hinges on exactly those temporal details. (Feedback Index: Structure and Sequence)

• 2.3Theme 3 — The modifying-factors heuristic

  The third heuristic asks what changes the complaint — what starts it, makes it worse, keeps it going, and takes it away. The answers are often the strongest clues to mechanism and to what will help.

  For the skills behind these exercises, see MAAS items 2.7, 2.8, 2.9, and 2.10 on this website, and Chapter 2 of the handbook (§ The Modifying-Factors Heuristic) for the reasoning.

  1. Recognition — Provoking vs. maintaining

  Goal

  Recognise the difference between a question about what starts the complaint and a question about what keeps it going.

  Task

  A patient reports daily headaches. Which question asks about a maintaining factor (what keeps it going), rather than a provoking one (what starts it)?

  • A) “Was there something that triggered the first one?”
  • B) “Is there anything about your daily routine that might be keeping these going?”
  • C) “Do you get them after meals?”
  • D) “What were you doing when the last one came on?”

  Reveal answer

  B asks about a maintaining factor. A and D ask about onset — what provoked a specific headache. C asks about an aggravating factor (what makes a given episode worse). B asks about a pattern that could be sustaining the problem week after week — sleep, caffeine, posture, stress, medication overuse. The four modifying factors are different questions with different answers. (MAAS 2.9)

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  2. Reformulation — Open question about triggers

  Goal

  Rewrite a closed trigger question into one that invites the patient to notice patterns.

  Task

  Rewrite this so the patient can tell you what they have noticed, rather than confirm a list:

  “Is it caused by stress, food, or not sleeping?”

  Reveal exemplars

  Exemplars:

  • “Have you noticed anything that seems to set it off?”
  • “When does it tend to come on?”
  • “What do you think triggers it?”

  The original offers three candidate triggers and implicitly closes off a fourth or fifth. The exemplars let the patient describe what they have observed — which is often richer than a checklist. A patient may tell you the headaches come on when their neighbour plays loud music, or on the fourth day of every monthly cycle, or after red wine. None of those would appear on a standard list. (MAAS 2.7)

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  3. Apply to case — The four modifying factors

  Goal

  Ask one question for each of the four modifying-factor dimensions in a single case.

  Task

  A patient has described recurring epigastric pain over the past three months. Write one question for each dimension:

  • Provoking (what starts it): _____
  • Aggravating (what makes it worse once it’s there): _____
  • Maintaining (what keeps it going over time): _____
  • Relieving (what takes it away): _____

  Reveal exemplars

  Exemplars:

  • Provoking: “What brings it on?”
  • Aggravating: “Once it starts, what makes it worse?”
  • Maintaining: “Is there anything that keeps this going over the weeks?”
  • Relieving: “What takes it away, or makes it easier?”

  Compare your four with the exemplars. Notice that each one asks about a different stage of the episode — beginning, worsening, persistence, ending. In epigastric pain the answers separate reflux from peptic ulcer from functional dyspepsia. The four together tell a story that any single question cannot. (MAAS 2.7–2.10 · H3)

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  4. Ordering — Modifying factors in sequence

  Goal

  Put the four modifying-factor questions in an order that feels natural in conversation.

  Task

  A patient has just described intermittent joint pain. Put these in the order you would ask them:

  • “What makes it better?”
  • “Is there anything that might be keeping it going week after week?”
  • “What brings it on?”
  • “Once it starts, what makes it worse?”

  Reveal answer

  A natural sequence follows the episode: Provoking → Aggravating → Relieving → Maintaining — what starts it, what worsens it, what helps, and what is keeping it around. Other orders work too. What matters is that your questions move with the arc of a single episode, rather than jumping between dimensions. Reading your sequence aloud will tell you whether the flow feels like conversation. (MAAS H3)

• 2.4Theme 4 — The context heuristic

  No complaint exists in isolation. The fourth heuristic asks what accompanies the main symptom and what surrounds the patient — other body systems, the circumstances of daily life, and the social determinants that shape both exposure and recovery.

  For the skills behind these exercises, see MAAS items 2.11, 2.12, and 2.13 on this website, and Chapter 2 of the handbook (§ The Context Heuristic) for the reasoning.

  1. Recognition — Accompanying symptoms that matter

  Goal

  Recognise the question that opens space for other symptoms the patient may not have volunteered.

  Task

  A patient has described abdominal pain. Which question best invites them to mention other symptoms that may be connected?

  • A) “Do you have a fever?”
  • B) “Something else going on alongside this — changes in appetite, weight, bowels, sleep, mood?”
  • C) “Is there vomiting or diarrhoea?”
  • D) “Any nausea?”

  Reveal answer

  B opens the widest net. A, C, and D each ask about a single candidate symptom — useful as follow-ups, but each only finds what it names. B gives the patient the chance to mention something you had not thought to ask — a skin change, a mouth ulcer, a joint ache — that can reshape the differential. (MAAS 2.11)

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  2. Apply to case — The unresolved cough

  Goal

  Ask about contextual factors that may be sustaining or shaping the complaint.

  Task

  A 52-year-old has had a persistent cough for four months. The complaint heuristic and time-intensity heuristic are complete. Write one question that asks about the context surrounding the cough — things in the patient’s life or environment that may matter.

  Reveal exemplars

  Exemplars:

  • “What’s been going on in your life around the time this started?”
  • “Tell me a bit about where you live and work — any changes there?”
  • “Is there anything in your daily environment that could be connected — smoke, dust, pets, damp, new job?”

  Compare your version with the exemplars. Notice that each one widens the lens from the cough itself to the conditions around it. A four-month cough in someone who started a new job on a construction site is a different clinical problem from the same cough in someone who moved in with a chain-smoking partner — and neither will come up unless you ask. (MAAS 2.12)

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  3. Spot-the-issue — Social determinants skipped

  Goal

  Notice when the physician has collected a clean medical picture without asking about the patient’s social reality.

  Task

  Read this exchange. What is missing?

  Patient: The asthma has been worse the past few months — I’m using the inhaler almost every day now.
  Physician: Have you been taking the preventer regularly?
  Patient: Mostly. Sometimes I run out for a few days.
  Physician: OK, let’s make sure we get you back on track with that.

  Reveal answer

  2.13 is missing — the social determinants are unexplored. Running out of medication is rarely about forgetting; it is often about cost, pharmacy access, unstable housing, or chaotic work hours. Asking “What makes it hard to have the preventer when you need it?” uncovers the real barrier. Without that question, the advice to “get back on track” is addressed to a problem that isn’t there. (Feedback Index: Social Context)

• 2.5Theme 5 — The psychosocial-impact heuristic

  The fifth heuristic asks how the complaint has reshaped the patient’s life — the psychological weight, personal functioning, work, social life, and sometimes the roles the illness has started to play for them. This is where the clinical picture meets the biography.

  For the skills behind these exercises, see MAAS items 2.14, 2.15, 2.16, 2.17, and 2.18 on this website, and Chapter 2 of the handbook (§ The Psychosocial-Impact Heuristic) for the reasoning.

  1. Recognition — Beyond “how are you?”

  Goal

  Recognise a question that actually maps the psychosocial impact, rather than inviting a polite brush-off.

  Task

  A patient has described chronic fatigue for a year. Which follow-up reaches the psychosocial impact most fully?

  • A) “How has this affected your mood?”
  • B) “Is your work OK?”
  • C) “How has this affected your mood, your work, your time with people, and the things you do for yourself?”
  • D) “Can you still do everything?”

  Reveal answer

  C maps the fullest picture. A and B each name one domain; useful, but each closes the others. D invites a yes/no that tells you nothing specific. C names several domains at once, signalling that all of them are fair game — mood, work, relationships, self-care — and letting the patient tell you which has taken the biggest hit. (MAAS 2.14–2.17)

  ---

  2. Reformulation — From a single-word answer to a story

  Goal

  Rewrite a closed work question into one that elicits a real description of functioning.

  Task

  Rewrite this so the patient describes how work is actually going, rather than confirming a state:

  “Can you still work?”

  Reveal exemplars

  Exemplars:

  • “What’s work like for you at the moment?”
  • “Has this changed what you can do in a day at work?”
  • “Tell me what a work day looks like now compared with six months ago.”

  The original invites “yes” or “no” — neither answer tells you much. The exemplars invite the patient to describe, which is where nuance lives: still working but exhausted by Tuesday, hiding it from colleagues, turning down responsibilities, taking sick days that are not reported. These details shape both severity and treatment. (MAAS 2.16)

  ---

  3. Apply to case — Mapping fatigue across domains

  Goal

  Ask about the fatigue’s impact across the psychosocial domains.

  Task

  A 40-year-old returns after six months of fatigue. Blood work is unremarkable. Write one question for each domain:

  • Psychological (mood, worry): _____
  • Personal functioning (self-care, routine): _____
  • Work or school: _____
  • Social & leisure: _____

  Reveal exemplars

  Exemplars:

  • Psychological: “How has this been on you emotionally?”
  • Personal functioning: “Has this changed your day-to-day routines — cooking, shopping, looking after yourself?”
  • Work: “What’s work been like through this?”
  • Social & leisure: “Has this changed what you do with friends or for fun?”

  Compare your four with the exemplars. Notice that together they form a map — one domain at a time, each giving the patient a chance to tell you what has shifted. Most chronic complaints have affected all four; the patient often waits for permission to describe it. (MAAS 2.14–2.17 · H5)

  ---

  4. Spot-the-issue — Secondary gain unexplored

  Goal

  Notice when the benefits a complaint has started to carry (the role it plays for the patient) have not been asked about.

  Task

  Read this exchange. What dimension of the psychosocial impact has the physician not touched?

  Patient: I’ve had this lower-back pain for nearly two years now. I’m off work most weeks. It’s really getting me down.
  Physician: That sounds very tough. Has your mood been low?
  Patient: Yes, quite.
  Physician: Let’s talk about pain management.

  Reveal answer

  2.18 has not been asked about — the ways the complaint may have begun to serve a role in the patient’s life. This is delicate territory: the back pain may be providing relief from a job the patient dreads, maintaining a relationship through caregiving, or generating an income through long-term sick leave. None of this means the pain is not real. Asking, gently, “Is there anything about your situation that being unwell has made easier?” often opens the conversation the treatment will need. (Feedback Index: Psychosocial Context)

• 2.6Theme 6 — The staging heuristic

  The sixth heuristic places the current consultation in the patient’s medical trajectory: past illnesses, past treatments, who else is currently involved in their care, and what medication they are taking now. Without this, your treatment plan sits in mid-air.

  For the skills behind these exercises, see MAAS items 2.19, 2.20, 2.21, and 2.22 on this website, and Chapter 2 of the handbook (§ The Staging Heuristic) for the reasoning.

  1. Recognition — Who else is already involved?

  Goal

  Recognise the question that reveals what other professionals are currently treating or monitoring the patient.

  Task

  A patient has described persistent joint pain. Which question best maps the other clinicians currently involved in their care?

  • A) “Have you seen anyone else about this?”
  • B) “Are you seeing anyone else at the moment — a specialist, physio, or other doctor — for this or something else?”
  • C) “Any other health problems?”
  • D) “Are you under a specialist?”

  Reveal answer

  B covers the full current picture. A only asks about this complaint. C asks about conditions, not clinicians. D defines “help” narrowly as a specialist, missing physios, psychologists, alternative therapists, and practice nurses. B names several kinds of involvement — with an “or something else” that catches the care you might not have anticipated. (MAAS 2.21)

  ---

  2. Reformulation — A medication question that gets the full picture

  Goal

  Rewrite a narrow medication question into one that surfaces everything the patient is actually taking.

  Task

  Rewrite this so the patient describes their actual medication habits:

  “Are you on any medication?”

  Reveal exemplars

  Exemplars:

  • “Can you walk me through everything you are taking at the moment — prescription, over-the-counter, vitamins, herbal, anything?”
  • “What do you take regularly, and what do you take only when you need it?”
  • “Tell me about your medications — what, how often, and whether you take them as prescribed.”

  The original gets a list of prescriptions. The exemplars get the real picture: the daily paracetamol for “not much,” the herbal supplement a friend recommended, the antibiotic finished last week, the blood-pressure tablet taken “when I remember.” Interactions and non-adherence both hide in that gap. (MAAS 2.22)

  ---

  3. Apply to case — A new visit for old back pain

  Goal

  Use the full staging heuristic to place a new consultation in the patient’s medical history.

  Task

  A patient returns with a flare-up of back pain they have had on and off for ten years. Write one question for each dimension of the staging heuristic:

  • Past illnesses (relevant conditions the patient has had): _____
  • Past treatments (what has been tried for this or related problems): _____
  • Current consultations (who else is treating them now): _____
  • Current medications: _____

  Reveal exemplars

  Exemplars:

  • Past illnesses: “Any other medical problems, past or ongoing, that might be relevant?”
  • Past treatments: “What has been tried for the back over the years — medications, physio, procedures?”
  • Current consultations: “Are you seeing anyone else for this or for something else right now?”
  • Current medications: “What are you taking at the moment — regular, as-needed, something else?”

  Compare your four with the exemplars. Notice that together they give you the trajectory: what the body has been through, what has and has not worked, who else is in the picture, and what chemicals are currently circulating. A treatment plan built without this information is a plan built for a stranger. (MAAS 2.19–2.22 · H6)

  ---

  4. Spot-the-issue — Treatment history missed

  Goal

  Notice when a treatment plan is being built without knowing what has already been tried.

  Task

  Read this exchange. What staging item has the physician overlooked?

  Patient: The headaches are back. They’re worse than before.
  Physician: I’m going to prescribe sumatriptan. Take one at the first sign of a migraine.
  Patient: OK.

  Reveal answer

  2.20 has been skipped. The headaches are back — meaning the patient has a treatment history, which was not asked about. Sumatriptan may be what they tried before and discontinued; it may be what their previous GP started them on; it may interact with a current medication. Asking “What has been tried for these in the past, and what worked?” takes twenty seconds and saves a wrong prescription. (Feedback Index: Clinical History)

• 2.7Theme 7 — Risk and vulnerability

  The seventh heuristic asks about the factors that shape a patient’s baseline risk: substance use, vulnerabilities carried from their biography, and family history. These are not always direct causes of the current complaint — but they change what the complaint could become, and how it should be treated.

  For the skills behind these exercises, see MAAS items 2.23, 2.24, and 2.25 on this website, and Chapter 2 of the handbook (§ The Risk and Vulnerability Heuristic) for the reasoning.

  1. Recognition — Asking about alcohol without judgement

  Goal

  Recognise the question that elicits an honest answer about alcohol use.

  Task

  You need to ask a patient about alcohol. Which question is most likely to get a truthful answer?

  • A) “You don’t drink much, do you?”
  • B) “Do you drink alcohol?”
  • C) “On a typical week, how many times do you have a drink — and roughly how much on those days?”
  • D) “Are you a heavy drinker?”

  Reveal answer

  C is the most informative. A signals the expected answer — most patients will oblige. B gets a yes/no that tells you nothing. D asks the patient to label themselves in a way few will accept. C asks for a behaviour, not a judgement, and splits the question into frequency and quantity — the two things that actually matter for risk. Ask the same way about tobacco and other substances. (MAAS 2.23)

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  2. Apply to case — Family history for chest pain

  Goal

  Ask about family history in a way that surfaces what is relevant to the current complaint.

  Task

  A 52-year-old man presents with new chest pain. You want to know his family cardiovascular history. Write one question that asks in a useful, specific way.

  Reveal exemplars

  Exemplars:

  • “Has anyone in your close family had heart trouble, particularly before the age of sixty?”
  • “Thinking of parents, siblings — any history of heart attacks, strokes, or sudden death?”
  • “Does heart disease run in your family? If so, who, and at what age?”

  Compare your version with the exemplars. Notice that each one narrows the question: close family, heart-specific, and where possible the age of onset. “My father died of a heart attack at fifty-six” is a very different signal from “my grandfather had heart trouble in his eighties.” Age of onset is what you are really after. (MAAS 2.25)

  ---

  3. Spot-the-issue — Biographical vulnerability overlooked

  Goal

  Notice when a complaint is being investigated without asking about the life experiences that may shape it.

  Task

  Read this exchange. What dimension has the physician not opened up?

  Patient: I’ve been getting these panic attacks again. They come out of nowhere — in supermarkets, on the bus.
  Physician: How long have you had them? Any triggers you’ve noticed?
  Patient: A few months. Not really triggers — they just come.
  Physician: Let’s think about treatment options.

  Reveal answer

  2.24 has not been opened — the patient’s biographical vulnerability. Panic attacks that “come out of nowhere” often have roots that are not visible from the complaint alone: childhood adversity, trauma, grief, a previous episode the patient has not connected to the current one. Asking, gently, “Has anything in your life, past or present, felt like it might be connected to this?” opens the door without demanding a history the patient may not be ready to tell. Whether the door is walked through is the patient’s choice. (Feedback Index: Biographical Context)

  You’ve just worked through the foundation of the medical interview — exploring Reasons for Encounter and history-taking. The remaining chapters are on the way.

3Chapter 3. Review of Systems

• 3.1Theme 1 — The constitutional screen

  Three questions to ask every patient, every consultation. Weight loss, fever or night sweats, energy — the constitutional screen catches serious systemic disease early and takes thirty seconds. This theme practises asking them, recognising what they cover, and spotting when they have been skipped.

  For the skill behind these exercises, see MAAS item 2.26 on this website, and Chapter 3 of the handbook (§ Tier 1 — Constitutional Screen) for the reasoning.

  1. Recognition — Which three questions are the constitutional screen?

  Goal

  Recognise the three-question bundle that screens for serious systemic disease.

  Task

  You are about to do your tier-1 constitutional screen on a new patient. Which set of questions is it?

  • A) “Any pain? Any shortness of breath? Any cough?”
  • B) “Any unexplained weight loss? Any fevers or night sweats? How’s your energy?”
  • C) “Do you have any other health problems? Any allergies?”
  • D) “How’s your appetite? How’s your sleep? How’s your mood?”

  Reveal answer

  B is the constitutional screen. A asks about specific-system symptoms — useful, but not constitutional. C is past medical history, not current screening. D is a valuable psychosocial screen but does not catch malignancy, infection, or metabolic disease. B asks the three questions that together flag serious systemic illness: a positive answer to any one of them reshapes the consultation. (MAAS 2.26)

  ---

  2. Commit-then-compare — Asking about weight loss

  This is a new kind of exercise. Write your answer down first, then reveal the exemplars. The learning is in the comparison — both of your wording, and of the reasoning you used.

  Goal

  Ask about weight loss in a way that catches what the patient may not have volunteered.

  Task

  A 58-year-old woman is in your consultation for recurrent headaches. You are about to ask about weight as part of the constitutional screen. Write down the exact words you would use, and one sentence on why you chose those words, before revealing.

  Reveal exemplars and reasoning

  Exemplars:

  • “Have you noticed any unexplained weight loss?”
  • “Any changes in your weight that you haven’t been trying for?”
  • “Has your weight been steady over the past few months?”

  The word “unexplained” does most of the work. Patients often dismiss weight loss (“I’ve been busy”, “I’m dieting”) — asking about unexplained loss prompts the answer that carries diagnostic weight. Notice what is absent: no one asks “how much have you lost?” That’s a follow-up, once loss is confirmed. The screening question just establishes whether there is loss to investigate at all. Compare your wording with the exemplars — and compare your reasoning with the one above. (MAAS 2.26)

  ---

  3. Spot-the-issue — Constitutional screen skipped

  Goal

  Notice when the tier-1 screen has been missed in a presentation that needs it.

  Task

  Read this exchange. What has the physician skipped?

  Patient: I’ve had a cough for about three months now. It’s dry, mostly at night.
  Physician: Any shortness of breath? Any wheeze? Chest pain?
  Patient: No to all of those.
  Physician: OK — let’s have a look and listen to your chest.

  Reveal answer

  The constitutional screen (item 2.26, tier 1) has been skipped. A three-month cough in an adult needs the three constitutional questions before the examination — weight loss, fever or night sweats, energy. Any one of them positive makes this a very different consultation (tuberculosis, lymphoma, lung malignancy). The respiratory-system questions are useful but they do not catch what the constitutional ones catch. Thirty seconds of screening, before the stethoscope. (Feedback Index: Red Flags)

  ---

  4. Commit-then-compare — The screen for a new headache

  Goal

  Use the full constitutional screen in a real clinical situation.

  Task

  A 34-year-old man has had headaches for three weeks — new for him. Before something else, you want to do the constitutional screen. Write down the three questions you would ask, in the order you would ask them, before revealing.

  Reveal exemplars and reasoning

  Exemplars:

  • “Have you noticed any unexplained weight loss?”
  • “Any fevers or night sweats?”
  • “How has your energy been — has it changed?”

  Compare your three with the exemplars. Notice that each asks for a specific observation — weight, fever/sweats, energy — not a general “how are you?” With new headache in a young adult, most of the time all three will be negative, and that is clinically useful reassurance. But a positive answer to any of them reframes the consultation from tension headache toward something that may need imaging or blood work. The screen takes thirty seconds and catches the small fraction of cases where a serious diagnosis hides inside a common complaint. (MAAS 2.26)

• 3.2Theme 2 — From complaint to systems

  Given a patient’s chief complaint, which other systems deserve a look? This theme practises that move on three manageable complaints — sore throat, headache, back pain — before the chapter turns to harder ones.

  For the skill behind these exercises, see MAAS item 2.26 on this website, and Chapter 3 of the handbook (§ Tier 2 — Targeted System Review) for the reasoning.

  1. Recognition — Sore throat: which systems deserve a check?

  Goal

  Recognise which systems a sore-throat presentation connects to.

  Task

  A patient has had a sore throat for four days. Beyond the throat itself, which set of systems is most relevant to review?

  • A) ENT, respiratory, constitutional
  • B) Gastrointestinal, genitourinary, musculoskeletal
  • C) Neurological, dermatological, endocrine
  • D) Cardiovascular, haematological, ophthalmological

  Reveal answer

  A covers the relevant systems. ENT for lymph nodes, ears, nasal involvement; respiratory for cough or breathing difficulty; constitutional for fever, weight loss, energy — the screen for glandular fever, abscess, or something more sinister in a persistent sore throat. B pulls in three systems (GI, GU, MSK) that rarely connect to an isolated sore throat; asking wastes consultation time and invites confusion. C similarly reaches for systems (neuro, skin, endocrine) whose connection to the complaint would be surprising rather than expected. D asks about cardiovascular, haematological, and ophthalmological systems — again unlikely to be yielding here, unless a specific cluster (e.g. recurrent severe infections) flagged haematological screening. The skill is to target the systems the complaint most plausibly opens onto, not to cast a wide net. (MAAS 2.26)

  ---

  2. Commit-then-compare — Headache: systems beyond neurology

  Goal

  Name the systems you would screen in a new headache, beyond the neurological examination.

  Task

  A 40-year-old woman has had worsening headaches for two weeks. Write down two or three other systems (besides neurological) you would screen, and one sentence on why. Then reveal.

  Reveal exemplars and reasoning

  Exemplars:

  • ENT — sinus involvement, visual symptoms, ear disease
  • Constitutional — weight, fever, night sweats (giant cell arteritis, malignancy, systemic infection)
  • Cardiovascular — hypertension, relevant in a new persistent headache

  Compare your systems with the exemplars. Notice that the link between headache and ENT, constitutional, and cardiovascular is not obvious from the complaint alone — it comes from knowing what else presents with headache. This is why Review of Systems is a physician’s tool, not a patient’s. The patient sees their head; you see the possibility that the head is signalling something elsewhere. (MAAS 2.26)

  ---

  3. Apply to case — Back pain: what to screen

  Goal

  Decide what to screen for in a patient with new back pain.

  Task

  A 55-year-old man has had low back pain for six weeks. It is new. Before you reach for imaging, what questions from which systems would you ask? Write them down, then reveal.

  Reveal exemplars and reasoning

  Exemplars:

  • Constitutional: “Any unexplained weight loss? Fever or night sweats? How’s your energy?”
  • Genitourinary: “Any problems with passing urine — retention, incontinence, numbness around the back passage?”
  • Neurological: “Any weakness in your legs? Numbness or tingling?”

  Compare your list with the exemplars. Each category exists to catch a specific serious cause — constitutional for malignancy or infection, GU for cauda equina, neurological for spinal cord involvement. Back pain is the complaint; these questions are the red-flag net. Asking all three takes under a minute and is a professional standard for new back pain in adults over fifty. (MAAS 2.26)

  ---

  4. Spot-the-issue — Headache treated as neurology only

  Goal

  Notice when the chief complaint has been investigated without cross-system screening.

  Task

  Read this exchange. What has the physician missed?

  Patient: These headaches have been getting worse for the past month. I’ve never had them like this before. I’m 54.
  Physician: Any visual changes? Nausea? Weakness down one side?
  Patient: No to all of those.
  Physician: OK, let’s look at triggers — stress, caffeine, sleep.

  Reveal answer

  The physician has stayed inside the neurological system and skipped cross-system screening. New headache in someone over fifty carries a red flag: giant cell arteritis. That needs ENT questions (jaw claudication, scalp tenderness, visual disturbance) and constitutional (fever, weight, fatigue). None of these appear in the exchange. Cross-system screening is not thoroughness for its own sake — it is the move that catches the diagnosis the complaint alone hides. (Feedback Index: Red Flags)

• 3.3Theme 3 — High-value cross-system clusters

  Single symptoms mean little. Clusters mean a lot. This theme practises recognising the combinations that, together, tell you what one symptom alone could not: meningitis, pulmonary embolism, giant cell arteritis, diabetes presentation, B-symptoms, and connective-tissue disease.

  For the reasoning behind these clusters, see Chapter 3 of the handbook (§ Cross-System Patterns) and MAAS item 2.26.

  1. Recognition — The meningitis triad

  Goal

  Recognise the three-symptom cluster that points toward bacterial meningitis.

  Task

  Which combination, presenting together, should trigger urgent evaluation for meningitis?

  • A) Headache + nausea + sensitivity to light
  • B) Headache + fever + neck stiffness
  • C) Headache + fatigue + night sweats
  • D) Headache + blurry vision + dizziness

  Reveal answer

  B is the classical meningitis triad. Any two of the three should trigger same-day evaluation — sensitivity of this cluster for meningitis is around 95%. A and D describe migraine features; C points toward chronic systemic disease (lymphoma, tuberculosis). Clusters narrow diagnosis because each element has multiple causes alone, but only a small set of causes together. (MAAS 2.26)

  ---

  2. Recognition — The B-symptom cluster

  Goal

  Recognise the constitutional cluster that warrants investigation for malignancy or systemic disease.

  Task

  A patient presents with fatigue. Which additional combination most strongly suggests a malignancy or systemic infection?

  • A) Unexplained weight loss + night sweats + persistent fever
  • B) Muscle aches + poor sleep + low mood
  • C) Headache + stiff neck + nausea
  • D) Joint pain + morning stiffness + fatigue

  Reveal answer

  A is the B-symptom cluster — weight loss + night sweats + fever — classically associated with lymphoma and other haematological malignancies, and with tuberculosis. B describes depression or chronic fatigue. C is meningitis (Theme 3 Exercise 1). D suggests an inflammatory arthritis such as rheumatoid disease. The B-symptom cluster is one of the most useful patterns in general practice — it directs fatigue from “could be anything” toward “needs investigation this week.” (MAAS 2.26)

  ---

  3. Commit-then-compare — Given three symptoms, what do you suspect?

  Goal

  Use a three-symptom cluster to generate a specific diagnostic hypothesis.

  Task

  A 55-year-old woman presents with polyuria, polydipsia, and unexplained weight loss. Write down your best diagnostic hypothesis, and one sentence on why. Then reveal.

  Reveal exemplars and reasoning

  Best hypothesis: new-onset diabetes mellitus, most likely type 2.

  The cluster of polyuria + polydipsia + weight loss has a specificity above 95% for diabetes. None of the three is diagnostic alone: polyuria has genitourinary causes, polydipsia can be psychogenic, weight loss has dozens of differentials. Together, they point very strongly to a single diagnosis. Compare your hypothesis with this. If you reached for something else, notice the move: the skill is letting the combination do the diagnostic work, not each symptom in isolation. (MAAS 2.26)

  ---

  4. Apply to case — The unifying diagnosis question

  Goal

  Use the “what single diagnosis could explain all of this?” question to reframe a multi-system presentation.

  Task

  A 32-year-old woman has been tired for months. She has also been having joint aches in her hands, developed a rash on her cheeks after a beach weekend, and has recurrent painful mouth ulcers. Write down one diagnosis that could unify all four of these. Then reveal.

  Reveal exemplars and reasoning

  The cluster — fatigue + joint pain + photosensitive rash + oral ulcers — points toward systemic lupus erythematosus (SLE).

  Each symptom alone suggests a different specialty: fatigue is general, joint pain is rheumatology, rash is dermatology, mouth ulcers are dental. The unifying-diagnosis question — “what single diagnosis could explain all of this?” — is the move that catches multi-system disease. Y1-Y2 students are not expected to reach SLE cold; the point is to practise the question, which you can ask even when the answer is beyond your current knowledge. Tutors and reference materials then do the rest. (MAAS 2.26)

• 3.4Theme 4 — Red flags as clusters

  A single red-flag finding is a prompt. A cluster is an emergency. This theme practises spotting the combinations that demand same-day action — in headache, back pain, and chest pain — and reading red flags in context rather than as items on a checklist.

  For the presentation-by-presentation tables, see Chapter 3 of the handbook (§ Red Flags and Urgent Patterns), and MAAS item 2.26.

  1. Recognition — Headache red flag that needs same-day evaluation

  Goal

  Recognise a headache combination that needs urgent (not routine) evaluation.

  Task

  Which of these headache presentations needs evaluation today, not next week?

  • A) Tension headache returning after a busy week at work
  • B) New headache in a 72-year-old with scalp tenderness and brief loss of vision
  • C) Recurring migraine with aura, lasting four hours
  • D) Sinus headache with nasal congestion and fever for two days

  Reveal answer

  B needs same-day evaluation. The cluster — new headache over fifty + scalp tenderness + visual disturbance — fits giant cell arteritis, specificity around 98%. Untreated, it risks permanent blindness. A, C, and D are common primary or viral presentations that can be managed on a standard timeline. What makes B urgent is not any single element but the combination, read against the patient’s age. (MAAS 2.26)

  ---

  2. Commit-then-compare — Back pain with urinary retention

  Goal

  Recognise a back-pain red-flag cluster and act on it.

  Task

  A 48-year-old man has had severe low back pain for two days. He mentions that he had difficulty starting to urinate this morning. Write down your next two or three questions, and one sentence on what you suspect. Then reveal.

  Reveal exemplars and reasoning

  Your next questions should target cauda equina syndrome:

  • “Do you have any numbness around your groin, buttocks, or inner thighs — the ‘saddle’ area?”
  • “Any weakness in your legs, or loss of sensation below the waist?”
  • “Any loss of bowel control?”

  Cauda equina is a surgical emergency — delay costs permanent nerve damage. Urinary retention with back pain is one of the classic first signs; saddle anaesthesia and bilateral leg weakness are the cluster you are now testing for. A positive finding means emergency referral, not an outpatient MRI. The move is: one red-flag symptom raises suspicion, but you must ask about the cluster before you act. (Feedback Index: Red Flags)

  ---

  3. Spot-the-issue — Red flag inside reassuring features

  Goal

  Notice when a single alarming finding is being outweighed by otherwise reassuring features.

  Task

  Read this exchange. What should have stopped the physician?

  Patient: I had this sudden, really severe headache two hours ago. Worst I’ve ever had. It’s easing off now though.
  Physician: Any nausea? Stiff neck? Weakness?
  Patient: Bit of nausea. Neck feels fine. No weakness.
  Physician: It sounds like it’s settling. Let’s give it a few hours and see.

  Reveal answer

  The phrase “sudden, worst I’ve ever had” is a thunderclap headache — a red flag for subarachnoid haemorrhage regardless of whether symptoms improve. The physician has been reassured by the settling, the absent stiff neck, and the absent weakness. But the initial presentation alone warrants same-day neuroimaging. This is why red-flag recognition matters more than red-flag arithmetic: one high-specificity finding can outweigh several reassuring ones. Missing this, when it matters, is catastrophic. (Feedback Index: Red Flags)

  ---

  4. Apply to case — Chest pain red-flag cluster

  Goal

  Build the red-flag screen for chest pain.

  Task

  A 60-year-old presents with central chest pain that started an hour ago. Write down three questions that screen for the most dangerous causes. Then reveal.

  Reveal exemplars and reasoning

  Exemplars:

  • “Is the pain tearing, and does it go through to your back?” — screens for aortic dissection
  • “Are you breathless, and have your legs been swollen or tender?” — screens for pulmonary embolism
  • “Is the pain crushing, with sweating, nausea, or pain into your arm or jaw?” — screens for acute coronary syndrome

  Compare your three with the exemplars. Notice that each one is not a single question but a cluster — because the diagnostic power is in the combination. A chest pain assessment that asks only “where is the pain?” will miss dissection and pulmonary embolism. The screen is not a checklist; it is three focused two-part questions that each test a specific differential. (MAAS 2.26)

• 3.5Theme 5 — Tiered Review of Systems

  A complete Review of Systems can swallow a consultation. Efficiency is not about skipping — it is about tiering: the constitutional screen always; targeted systems based on the complaint; a full review only when it is genuinely warranted.

  For the tier structure, see Chapter 3 of the handbook (§ Efficient Review of Systems), and MAAS item 2.26.

  1. Recognition — When is a full (tier 3) review warranted?

  Goal

  Recognise the circumstances that justify a full, system-by-system review.

  Task

  Which patient most warrants a full tier-3 Review of Systems?

  • A) A 25-year-old with a sore throat for three days
  • B) A 70-year-old new to your practice with vague fatigue, weight loss, and multiple subtle complaints
  • C) A 40-year-old with a twisted ankle after football
  • D) A 30-year-old for a routine contraception review

  Reveal answer

  B needs the full review. A new elderly patient with vague, diffuse, multi-system features is exactly the presentation where something serious hides behind the word “fatigue.” A needs tier 1 plus ENT/respiratory. C needs a focused musculoskeletal assessment. D needs gynaecological and cardiovascular screening for contraception safety, not a full review. Tier 3 is for diagnostic uncertainty and for patients whose complaint resists placement in a single system. (MAAS 2.26)

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  2. Ordering — The tiered sequence

  Goal

  Put the review in the order that delivers the most information first.

  Task

  A 47-year-old presents with three weeks of mid-chest discomfort. Put these three in the order you would ask them, starting with tier 1.

  • Ear, skin, gastrointestinal, urinary (full review, system by system)
  • Cardiovascular, respiratory, gastrointestinal (targeted to the complaint)
  • Weight loss, fever or night sweats, energy (constitutional screen)

  Reveal answer

  The sequence is Tier 1 → Tier 2 → Tier 3:

  1. Weight loss, fever or night sweats, energy — constitutional screen (thirty seconds, always)
  2. Cardiovascular, respiratory, gastrointestinal — targeted to chest pain (one to two minutes)
  3. Ear, skin, GI, urinary — full review, only if the first two tiers leave uncertainty

  The point of the sequence is that each tier adds information proportional to its time cost. Tier 1 takes thirty seconds and catches systemic disease. Tier 2 takes a minute or two and tests the differential the complaint suggests. Tier 3 is reserved for cases where the picture still has not resolved. A student who jumps to tier 3 on every patient runs out of consultation time; a student who skips tier 1 misses the serious diagnosis. (MAAS 2.26)

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  3. Recognition — Cluster questions vs. individual probes

  Goal

  Recognise the question that scans a system without producing a long list.

  Task

  Which question most efficiently screens the respiratory system?

  • A) “Any cough? Any shortness of breath? Any wheezing? Any chest tightness? Any phlegm?”
  • B) “Any problems with your breathing or chest?”
  • C) “Do you smoke?”
  • D) “When was your last chest X-ray?”

  Reveal answer

  B is the cluster question. It scans the respiratory system in one move, and invites the patient to volunteer anything abnormal in their own words. If the answer is positive, you probe specifics; if negative, you move on. A is a five-question interrogation that often gets five “no”s — because patients zone out, not because they have no symptoms. C and D are not system-screens at all. Cluster questions save time without losing information, provided you are ready to probe on a positive. (MAAS 2.26)

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  4. Commit-then-compare — Tier 2 for chest pain

  Goal

  Design a tier-2 targeted review for a specific complaint.

  Task

  Your 47-year-old with three weeks of chest discomfort has had the constitutional screen (tier 1). All three negative. You now move to tier 2 — a targeted system review. Write one cluster question for each relevant system, in the order you would ask. Then reveal.

  Reveal exemplars and reasoning

  Exemplars:

  • Cardiovascular: “Any problems with your heart — palpitations, ankle swelling, breathlessness on walking uphill?”
  • Respiratory: “Any problems with your breathing or chest — cough, wheeze, phlegm?”
  • Gastrointestinal: “Any reflux, heartburn, or pain that comes on with food?”

  Compare your three with the exemplars. Notice that each is a cluster (not a single question) and each targets a plausible differential — cardiac, pulmonary, oesophageal — for chest discomfort. Three targeted questions take about ninety seconds and narrow the differential substantially. If all three are negative, a serious cause becomes much less likely. If one opens up, you have found the next direction. (MAAS 2.26)

• 3.6Theme 6 — Integration and the ceiling

  This theme brings the earlier themes together in a case, and closes the chapter with an honest question: what can be practised alone, and what needs clinical exposure? Review of Systems is a skill that begins on this page and finishes at the bedside.

  For the integrating reasoning, see Chapter 3 of the handbook (§ From Pattern to Action), and MAAS item 2.26.

  1. Apply to case — A full integration

  Goal

  Use the tiered approach in a full case: constitutional screen, targeted review, cluster recognition, red-flag awareness.

  Task

  A 46-year-old man arrives with a two-month cough. He is otherwise well, he says. He has no obvious fever. The cough is dry, worse at night. Write your plan:

  • Tier 1 (three constitutional questions): _____
  • Tier 2 (two or three targeted cluster questions): _____
  • Any red-flag cluster you want to specifically rule out: _____

  Write your full plan before revealing.

  Reveal exemplars and reasoning

  Exemplars:

  • Tier 1: “Any unexplained weight loss? Any fevers or night sweats? How’s your energy?”
  • Tier 2 — respiratory: “Any shortness of breath, wheezing, phlegm, or blood in what you bring up?”
  • Tier 2 — cardiac: “Any swelling in your ankles, or breathlessness when walking uphill?”
  • Red-flag cluster: B-symptoms for lymphoma or tuberculosis (weight loss + night sweats + fever) — catch-all already in tier 1, but worth naming as the cluster you are alert for

  Compare your plan with the exemplars. Notice that tier 1 does double duty: it screens for systemic disease generally, and it tests for a specific cluster (B-symptoms) that matters enormously for a two-month cough. Tier 2 narrows into the systems that most plausibly account for the cough. The whole plan takes about three minutes and covers more ground than a fifteen-minute ad-hoc interrogation would. (MAAS 2.26 · H1-H4)

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  2. Commit-then-compare — The next question

  Goal

  Decide the next question to ask when the initial screen has turned up something.

  Task

  The patient above tells you, in answer to your tier-1 screen, that his energy is down, and he has lost a few kilograms he cannot explain. No fevers. Write your next question — and one sentence on why. Then reveal.

  Reveal exemplars and reasoning

  Exemplars:

  • “How much weight have you lost, over what period, and had you been trying?”
  • “Any night sweats, even if you haven’t had daytime fevers?”
  • “Have you noticed any lumps or swellings — in your neck, armpits, or groin?”

  Reasoning: two of three B-symptoms are now present. The move is to complete the cluster (night sweats) and to look for the physical sign that would consolidate the diagnosis (lymphadenopathy). This is where Review of Systems becomes diagnostic reasoning, not screening. Compare your next question and your reasoning with the exemplars. If you went straight to imaging or bloods without asking these, notice the move: the cluster question changes the clinical path before any test is ordered. (MAAS 2.26)

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  3. Reflection — what this chapter can and cannot teach

  Goal

  Name what you can now do, and what you still need the clinic to teach you.

  Task

  Take five minutes with these four prompts. Write by hand or on screen — they are for you, not for submission.

  1. Name one pattern from this chapter that you feel you could recognise tomorrow.
  2. Name one patient type this chapter has not prepared you for.
  3. What skill in Review of Systems do you think will only develop through real consultations?
  4. What would you bring to your tutor this week to take this forward?

  Reveal reflections

  This exercise has no answer key. What matters is that you can name, in your own words, what you carry forward from this chapter and what remains open.

  Review of Systems is not a skill you finish on paper. It begins with recognisable patterns — the constitutional screen, the meningitis triad, the B-symptom cluster, the tiered approach — and deepens through clinical exposure, through the felt experience of running out of time, through tutors pushing back on your choices, and through cases that do not fit the textbook. What this chapter has given you is scaffolding. Clinical years put muscle on it.

  If you finished this chapter feeling that some answers were beyond your current reach, that is the appropriate response. Bringing that honest picture to your tutor — with specific questions, not general uncertainty — is how the next stage of learning begins. (MAAS 2.26)

  That completes the current MAAS-PREP chapters. You have worked through exploring Reasons for Encounter, history-taking, and review of systems — the diagnostic phase of the consultation. The chapters on presenting solutions, process skills, flow, and the patient journey are on the way.

4Chapter 4. Presenting Solutions

• 4.1Theme 1 — The 50% problem and the shape of information

  Patients recall roughly fifty per cent of what physicians tell them, and about half of that is incorrect — treatment instructions forgotten far more often than the diagnosis. This theme introduces the frame for the whole chapter, and practises the single most effective antidote: structuring information like a book. Structure alone improves recall by 17% in general, and by 42% in patients with limited health literacy.

  For the reasoning, see Chapter 4 of the handbook (§ The 50% Problem · § Structuring Information Like a Book). No single MAAS item covers structure directly — it is a foundation move that shapes items 3.1, 3.2, 3.3, and 3.8.

  1. Recognition — Which explanation is structured like a book?

  Goal

  Recognise the book-structure pattern (title → chapters → details → summary) in an information-giving moment.

  Task

  A physician explains a new migraine diagnosis. Which of these openings follows the book-structure pattern?

  • A) “You have migraines. Let me write a prescription and a leaflet will explain the rest.”
  • B) “What we’re dealing with is migraine. I’d like to explain three things: what it is, what triggers it, and how we can treat it. Let’s start with what it is…”
  • C) “Migraines are a common neurovascular condition, with multifactorial triggers, and a range of abortive and prophylactic pharmacological options…”
  • D) “So you’ve got migraine. A lot of people have it. It’s usually fine.”

  Reveal answer

  B follows the book pattern: it states the topic (migraine), signposts three chapters (what it is, what triggers it, how we treat it), and promises to open the first. A skips straight to prescription with no framing — the patient has nothing to hang the information on. C uses terms that lose a Y1 student, let alone a patient. D sounds friendly but delivers no structure and no content. The book structure is what lifts recall from ~50% to ~65% in general, and dramatically higher in low-health-literacy populations. (MAAS 3.1)

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  2. Reformulation — Give an unstructured explanation a shape

  Goal

  Rewrite a flat information dump using title, chapters, details, summary.

  Task

  A physician tells a patient with newly diagnosed asthma: “Asthma means your airways get tight sometimes, we’ll give you two inhalers, one for every day and one for when it’s bad, you’ll need to avoid smoking and dust, come back in six weeks.”

  All the content is there. But there is no structure. Rewrite the same information using the book pattern — title, chapters (three), details, brief summary.

  Reveal exemplar and feedback

  Exemplar:

  “I’d like to explain your asthma and what we’ll do about it. There are three things to cover: what’s happening in your airways, the two inhalers you’ll be using, and what to do if things get worse.
  First, what’s happening: your airways are tightening up when something irritates them…
  Second, the inhalers: one is for every day — to keep the airways relaxed — and the other is for relief when you feel an attack starting…
  Third, what to avoid and what to watch for: smoking and dust are the main triggers; if the rescue inhaler isn’t working, that’s your sign to come in.
  So: every-day inhaler, rescue inhaler, avoid the triggers, come back if things worsen. See you in six weeks.”

  Compare your version with the exemplar. Notice how the same words gain weight when signposted. The patient now has three mental folders to put the information in, and a summary to rehearse on the way home. This takes maybe fifteen seconds more than the original. (MAAS 3.1, 3.11)

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  3. Commit-then-compare — A thirty-second migraine explanation

  Goal

  Deliver a short, structured explanation of a new migraine diagnosis.

  Task

  A 28-year-old patient has had her migraines confirmed today. In under thirty seconds of speaking, explain what she has, using the book structure. Write it down before revealing.

  Reveal exemplar and feedback

  Exemplar:

  “You have migraine — a kind of headache that comes from blood vessels around the brain opening up more than they should. There are three things you’ll want to know: what triggers yours, what you can do when one starts, and when you should come back. Shall we take them one at a time?”

  Compare your version with the exemplar. The diagnosis (title) is named; three chapters are signposted; the patient is invited in rather than lectured at. Notice the last sentence — offering to take them one at a time, rather than ploughing through all three, respects the recall limit. Your version may be different and still work: what matters is that a title, chapters, and an invitation appeared inside thirty seconds. (MAAS 3.1)

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  4. Spot-the-issue — An information dump

  Goal

  Notice when information has been delivered without structure.

  Task

  Read this exchange. What has the physician done that will reduce recall?

  Physician: So you have iron-deficiency anaemia, probably from your periods being heavy, we’ll give you iron tablets, take them with orange juice not tea, they can cause constipation and make your stools dark which is normal, come back in three months for a repeat blood test and if the fatigue doesn’t improve in six weeks or gets worse come back sooner, any questions?
  Patient: Erm … no, I think that’s clear.
  Physician: Great.

  Reveal answer

  The physician has delivered every correct piece of information in a single sentence, with no title, no chapters, and no summary. The patient will likely leave with the diagnosis and not much else — treatment instructions are the first casualty when structure is missing, and the patient’s “I think that’s clear” does not mean it was clear. The fix costs fifteen seconds: “I want to explain three things — what this is, what we’ll do about it, and when to come back.” Without that frame, the recall data predicts roughly half of this is lost, and a third of what is remembered will be wrong. (Feedback Index: Information Giving)

• 4.2Theme 2 — Phase 1: Explaining diagnosis, causes, prognosis, resources

  Phase 1 delivers the information: what is happening, why, what will happen next, and where to learn more. Each answer responds to a question the patient is asking in their head, whether or not they say so out loud. This theme practises making each answer concrete, causal, and memorable.

  For the skills behind these exercises, see MAAS items 3.1, 3.2, 3.3, and 3.8 on this website, and Chapter 4 of the handbook (§ Part 2 — Information Provision).

  1. Recognition — Concrete vs. jargon diagnosis explanation

  Goal

  Recognise the diagnosis explanation that a patient can actually visualise.

  Task

  A patient has been told they have GERD. Which follow-up sentence will they remember tomorrow?

  • A) “Gastroesophageal reflux disease is a functional disorder of the lower oesophageal sphincter.”
  • B) “Acid from your stomach is coming back up into the tube that connects your throat and stomach. That tube isn’t built for acid, so it burns.”
  • C) “It’s GERD. The acronym stands for gastroesophageal reflux disease.”
  • D) “Reflux. Very common. Nothing to worry about.”

  Reveal answer

  B gives the patient a model they can see. The location is named in words they use (“the tube that connects your throat and stomach”), the mechanism is simple (acid in the wrong place), and the symptom is explained (that is why it burns). A is accurate and useless — nothing here will be recalled. C gives the acronym without the picture. D reassures without teaching. The diagnostic test for this item is simple: could the patient draw what you said? (MAAS 3.1)

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  2. Reformulation — “We don’t know what causes this”

  Goal

  Turn a bare “we don’t know” into a framework the patient can work with.

  Task

  A patient asks what causes their recurrent tension headaches. The current response: “We don’t really know exactly what causes these.” True, but unhelpful. Rewrite it in a way that acknowledges uncertainty while giving the patient something to hold on to.

  Reveal exemplar and feedback

  Exemplar:

  “We don’t have a single cause for these, but we know quite a bit about what sets them off. The muscles around the head and neck tighten up under certain conditions — poor sleep, stress, too much screen time, sometimes caffeine shifts. Part of managing them is noticing your own pattern.”

  Compare yours with the exemplar. The key move: shifting from “we don’t know” to “here is what we do know”. Patients need a framework more than a definitive answer. The framework also hands them agency — notice the pattern — which is what will actually reduce the headaches over time. (MAAS 3.2)

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  3. Reformulation — A prognosis with three elements

  Goal

  Give a prognosis that includes expected course, red flags, and a timeline.

  Task

  A patient has viral bronchitis. The current prognosis: “It’ll probably clear up on its own.” Rewrite it with three elements: what you expect, what should bring them back earlier, and when to follow up.

  Reveal exemplar and feedback

  Exemplar:

  “Most people are over this in one to two weeks. If the cough is still there in three weeks, or if you develop a fever, shortness of breath, or start coughing up blood, please come back sooner. Otherwise, I’ll see you in two weeks only if you’re not feeling better.”

  Compare yours with the exemplar. Each of the three elements does a specific job: the expected course is reassurance, the red flags are safety netting in miniature, and the timeline gives the patient a clear next step. Without the red flags the reassurance risks being false reassurance; without the timeline the patient doesn’t know when “not getting better” starts. (MAAS 3.3)

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  4. Apply to case — Resources for a new migraine diagnosis

  Goal

  Offer specific, reliable resources — not “Google it.”

  Task

  The 28-year-old with a new migraine diagnosis asks where she can learn more. Write down two or three specific resources you would point her to, and one sentence on why.

  Reveal exemplar and feedback

  Exemplar:

  • A national neurological association website (e.g. The Migraine Trust, Brain & Spine Foundation) — reliable, patient-oriented, free
  • A headache diary app or paper template — helps her identify her own triggers, which is what will actually change her migraine pattern
  • The NHS (or equivalent national health service) patient information page on migraine — a good short reference written for a general reader

  Compare yours with the exemplar. Notice that all three are named — you are directing the patient to particular places, not to the open internet. Saying “Google migraine” exposes the patient to frightening misinformation. The diary is the resource that will do the most work — managing migraines is largely pattern recognition, and the patient is the only person who can collect those data. (MAAS 3.8)

• 4.3Theme 3 — Phase 2a: Exploring what matters and offering options

  Before presenting treatment, understand what the patient is hoping for and what they fear. Then present options — because options exist even when one is clearly better. This theme practises the move from physician monologue to shared conversation.

  For the skills behind these exercises, see MAAS items 3.4, 3.5, and 3.6 on this website, and Chapter 4 of the handbook (§ Part 3 — Shared Decision-Making).

  1. Recognition — Which question explores expectations?

  Goal

  Recognise a question that surfaces what the patient hopes for and fears about treatment.

  Task

  A patient has just heard their migraine diagnosis. Before you present options, which of these questions opens expectations most usefully?

  • A) “Do you want medication?”
  • B) “Before I go through the options, what are you hoping we can achieve — and is there anything about treatment that concerns you?”
  • C) “Have you tried anything already?”
  • D) “Any allergies?”

  Reveal answer

  B names the two things that will shape the rest of the conversation: what the patient hopes for (fewer migraines, less missed work, the ability to keep driving) and what they fear (dependency, side effects, stigma). A offers a yes/no and frames medication as the default. C is history-taking, already done. D is safety screening, not expectations. Without B, the physician will present options suited to a generic patient, not this one. (MAAS 3.4)

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  2. Reformulation — From generic to tailored

  Goal

  Rewrite a generic recommendation into one that shows you have listened.

  Task

  A patient has told you she is a long-distance lorry driver with chronic neck pain. The current recommendation: “This medication can cause drowsiness but it’s the most effective.” Rewrite this so that it addresses what she has just told you about her life.

  Reveal exemplar and feedback

  Exemplar:

  “The most effective medication for this can cause drowsiness — which is a problem for you, because you drive for a living. There’s a non-drowsy alternative that’s slightly less effective but wouldn’t affect your driving. Given what you’ve told me, I’d suggest we start with the non-drowsy one and see how you get on.”

  Compare yours with the exemplar. Notice what the rewrite does: it acknowledges the patient’s specific situation before delivering the recommendation, then pairs the recommendation to that situation. Tailoring does two things at once — it gives a better clinical fit, and it signals that the patient has been heard. Both improve adherence. (MAAS 3.6)

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  3. Commit-then-compare — Offering options for tension headache

  Goal

  Open the options space for a specific complaint in a way that signals choice exists.

  Task

  A patient has been diagnosed with recurrent tension headaches. You are about to discuss what to do next. Write one or two sentences that open options space — making clear that choices exist, before naming them. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “There are a few ways we could approach this. I’d like to go through them with you so we can pick what makes most sense for your situation.”
  • “We have a handful of reasonable options here — from doing nothing and watching, to lifestyle changes, to medication. Let me walk you through them.”
  • “Before I suggest anything, I want to say that there are several paths we could take with this. None of them is the one right answer.”

  Compare yours with the exemplars. Notice that each one establishes choice awareness before naming any specific option. This is what distinguishes shared decision-making from option-presenting — the patient is told, explicitly, that they are being asked to participate in a decision. “I’m going to start you on X” skips this move entirely. (MAAS 3.5)

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  4. Spot-the-issue — Prescribing without exploring

  Goal

  Notice when options have been closed off before the patient’s preferences were surfaced.

  Task

  Read this exchange. What has the physician skipped?

  Physician: You have type 2 diabetes. We’re going to start you on metformin — it’s the standard first-line. One tablet twice a day with food. I’ll arrange a diabetes nurse and a dietitian. Any questions?
  Patient: Um … no, I don’t think so.
  Physician: OK, prescription’s ready at the desk.

  Reveal answer

  The physician has delivered a plan without doing either half of Phase 2a. Expectations (3.4) were not explored — the patient may have come worried about injections, or hoping to try lifestyle change first, or afraid of weight gain from medication. Options (3.5) were not offered — metformin was presented as the only path. The patient’s quiet “no” is the classic signal of a patient who has already decided not to adhere and does not yet know how to say so. The fix costs sixty seconds at the start, before the prescription is written. (Feedback Index: Shared Decision-Making)

• 4.4Theme 4 — Phase 2b: Pros, cons, and arriving at a decision

  Numbers, choices, and the patient’s right to disagree. This theme covers how to discuss benefits and harms accurately, respect different opinions when they arise, and check whether the patient can actually do what has been agreed.

  For the skills behind these exercises, see MAAS items 3.7, 3.9, and 3.10 on this website, and Chapter 4 of the handbook (§ Part 3 — Shared Decision-Making, Item 3.7 onwards).

  1. Recognition — Absolute vs. relative risk

  Goal

  Recognise which framing of a risk-reducing treatment gives the patient an honest picture.

  Task

  A statin reduces a patient’s risk of a first heart attack from 3 in 1,000 per year to 2 in 1,000 per year. Which way of saying this gives the most accurate picture?

  • A) “This medication reduces your risk of a heart attack by a third.”
  • B) “Without treatment, about three people in a thousand would have a heart attack in the next year. With treatment, that drops to about two.”
  • C) “You’ve got a thirty-three per cent reduction in relative risk.”
  • D) “It cuts your chances significantly.”

  Reveal answer

  B is the most accurate. A and C are the relative-risk trap — technically correct, and misleading: a one-third reduction sounds dramatic, but the absolute benefit is one heart attack prevented per thousand people treated. Most patients, if told A, will overestimate the benefit to themselves by an order of magnitude. D gives no information at all. B uses absolute numbers and paints a picture the patient can weigh against side effects honestly. This is the single most important risk-communication move in the chapter. (MAAS 3.7)

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  2. Reformulation — From relative to absolute

  Goal

  Rewrite a relative-risk statement in absolute terms.

  Task

  A physician is explaining a new blood-pressure medication: “This will halve your risk of a stroke.” The baseline five-year stroke risk for this patient is about 4%, and the medication reduces that to about 2%. Rewrite the sentence in absolute terms the patient can actually weigh.

  Reveal exemplar and feedback

  Exemplar:

  “Out of a hundred people like you, about four would have a stroke in the next five years without this medication. With it, that drops to about two — so the medication prevents two strokes per hundred people treated over five years.”

  Compare yours with the exemplar. Two moves matter: the baseline is named (four in a hundred), and the absolute benefit is stated (two in a hundred). “Halve your risk” sounds like the medication is doing half the work of your body. “Two per hundred over five years” is what the medication is actually doing. Patients cannot weigh side effects against benefit unless the benefit is in numbers they can hold. (MAAS 3.7)

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  3. Commit-then-compare — When the patient disagrees

  Goal

  Respond to a patient who wants a different treatment from the one you recommend.

  Task

  You have recommended starting an antidepressant for a patient with moderate depression. The patient says: “I’d rather try therapy first. I don’t want medication.” Write down your next one or two sentences, and one sentence on your reasoning. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “That’s a perfectly reasonable choice. Therapy alone works well for moderate depression, especially if the fit with the therapist is good. Can I tell you what I’d want us to watch for, in case it isn’t enough on its own?”
  • “I hear you. Let’s go with therapy. I’d like us to check in after four to six weeks — if things aren’t moving, we can revisit medication together without it feeling like a failure.”
  • “Thanks for telling me that. Before we decide, can I ask what specifically worries you about the medication? I want to make sure my recommendation isn’t missing something.”

  Compare yours with the exemplars. Each exemplar does something different: accepting the patient’s choice with safety-netting, agreeing with a review point, or probing the concern without pressure. None of them argue. “Respecting different opinions” is not a formality — it is the move that determines whether the patient comes back honestly if therapy isn’t enough. (MAAS 3.9)

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  4. Apply to case — Willingness and ability

  Goal

  Check whether a plan that looks good on paper will survive daily life.

  Task

  You are starting a patient on an inhaled corticosteroid twice daily, plus a reliever as needed. They are a shift-worker with a three-year-old at home. Write two questions that check whether this plan will actually work for them day to day. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “Practically — would you be able to take the inhaler twice a day, given your shifts? When would you do it?”
  • “Is there anything you can see getting in the way — remembering it, affording it, fitting it around looking after your daughter?”

  Compare yours with the exemplars. Notice that both questions assume there will be obstacles — the physician is inviting the patient to name them now, not discovering them at the follow-up when adherence has already failed. A plan that survives contact with a three-year-old and shift work is a different plan from one that only works in the consultation room. (MAAS 3.10)

• 4.5Theme 5 — Phase 3: Instructions, teach-back, and safety netting

  Phase 3 is where treatment succeeds or fails. Patients are 2.16 times more likely to adhere when their physician communicates well; training in these skills improves adherence by 62%. Three moves: make instructions concrete, check that your explanation landed, and make the return visit legitimate.

  For the skills behind these exercises, see MAAS items 3.11, 3.12, and 3.13 on this website, and Chapter 4 of the handbook (§ Part 4 — Implementation).

  1. Reformulation — “Take this when you need it”

  Goal

  Turn a vague instruction into a concrete one.

  Task

  A patient has been prescribed sumatriptan for migraines. The current instruction: “Take this when you need it.” Rewrite it using all five elements of a concrete instruction: what to do, when, how much, what to avoid, and what to do if it doesn’t work.

  Reveal exemplar and feedback

  Exemplar:

  “Take one tablet at the first sign of a migraine — don’t wait until it’s fully developed, that’s the most common mistake. You can repeat the dose after two hours if the first one hasn’t worked, but not more than three tablets in twenty-four hours. Avoid taking it on more than ten days a month, because that causes rebound headaches. If you’re needing it more often than that, come back and let’s rethink.”

  Compare yours with the exemplar. Each of the five elements does a specific job: what and when make the action clear; how much and what to avoid set the limits; what if it doesn’t work turns the medication from a lottery into a plan. “Take this when you need it” produces under- and over-use. Five sentences produce adherence. (MAAS 3.11)

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  2. Recognition — Teach-back framing

  Goal

  Recognise the phrasing that checks your communication rather than testing the patient.

  Task

  You have just explained a new asthma action plan. You want to check that the explanation landed. Which phrasing does teach-back properly?

  • A) “Can you repeat back what I just said?”
  • B) “I want to make sure I explained that clearly. Can you tell me in your own words what you’re going to do when you get home?”
  • C) “Did you understand all of that?”
  • D) “Let’s test your understanding — what’s the name of the rescue inhaler?”

  Reveal answer

  B is the teach-back move. The responsibility for unclear communication stays with the physician (“I want to make sure I explained that clearly”), and the patient is asked to put the plan in their own words (which is what they will actually need to do). A sounds like an exam. C gets a polite “yes” and nothing else — worthless. D quizzes on a fact, not the plan. The framing matters because patients who feel tested will not report their confusion. Teach-back only works when it reveals what they do not yet know. (MAAS 3.12)

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  3. Reformulation — Teach-back that invites rather than tests

  Goal

  Rewrite a testing-tone teach-back into an inviting one.

  Task

  A physician says: “Tell me back what the three things I mentioned were.” True teach-back, wrong register. Rewrite it so the patient is invited, not tested.

  Reveal exemplar and feedback

  Exemplar:

  “I know I covered a lot. What will you tell your partner about this tonight?”

  Or:

  “So I know we’re on the same page — what are the main things you’ll be watching for over the next few days?”

  Compare yours with the exemplars. Notice the frame: the patient is not being asked to pass a test, they are being asked to rehearse the information for a real use (telling the partner, watching for changes). That rehearsal does two things: it reveals what is actually understood, and it strengthens recall through the act of explaining. Teach-back’s 45% reduction in hospital readmissions depends on the framing, not the technique. (MAAS 3.12)

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  4. Spot-the-issue — No safety net

  Goal

  Notice when a consultation ends without the return-visit conditions being set.

  Task

  Read this exchange. What has the physician not done?

  Physician: So, amoxicillin three times a day for seven days. Finish the whole course even if you feel better.
  Patient: OK. Thanks.
  Physician: Any questions? No? Good. Take care.

  Reveal answer

  The physician has delivered a concrete instruction (good) but has not done the other half of Phase 3 — the safety net. The patient has not been told what the expected course is, what would bring them back sooner, or when to check in if they are not improving. If the infection worsens, the patient will hesitate to return because no one gave them permission to. That hesitation is how pneumonia becomes sepsis. Safety netting takes thirty seconds and legitimises the return visit explicitly. (Feedback Index: Safety Netting)

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  5. Apply to case — Full safety net for a chest infection

  Goal

  Build the four elements of safety netting: expected course, red flags, how to seek help, follow-up timeline.

  Task

  The patient above has been started on amoxicillin for a chest infection. Before they leave, write down your safety net — four elements, one or two sentences each. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  • Expected course: “Most people start feeling better in two to three days.”
  • Red flags: “If you develop a high fever, shortness of breath, chest pain that’s getting worse, or if you start coughing up blood — come back right away.”
  • How to seek help: “During the day, call the surgery. Out of hours, go to the walk-in centre or A&E if you can’t reach us.”
  • Timeline: “If you’re not improving by Friday, I’d like a phone check-in — I’ll book it now.”

  Compare yours with the exemplar. All four elements together turn a prescription into a plan. Notice the last element: booking the follow-up now, not leaving it to the patient to remember. Patients who are not told when to return often do not; patients who are booked in usually come. This is safety netting that actually nets. (MAAS 3.13)

• 4.6Theme 6 — Integration: the three phases in a single consultation

  This theme brings the three phases together in a single case. The goal is to feel how they connect — Phase 1 shapes what Phase 2 can be, and Phase 2 determines whether Phase 3 will work.

  For the integrating reasoning, see Chapter 4 of the handbook (§ Part 6 — Expert vs. Novice), and MAAS items 3.1–3.13.

  1. Apply to case — A full consultation in miniature

  Goal

  Sketch the three phases for a single patient, one sentence per phase-element.

  Task

  A 55-year-old man has just been diagnosed with type 2 diabetes after a routine blood test. He is otherwise well. He works as a builder, has a demanding schedule, and mentions that his father was on insulin. Sketch:

  • Phase 1 (diagnosis, causes, prognosis, resources) — one sentence each
  • Phase 2 (what you would ask to explore expectations, and the options you would offer)
  • Phase 3 (one concrete instruction, one teach-back phrase, one safety net)

  Write down your sketch before revealing.

  Reveal exemplar and feedback

  Exemplar:

  Phase 1

  • Diagnosis: “Your blood sugar has been running high for a while — that’s type 2 diabetes, which means your body isn’t handling sugar the way it should.”
  • Causes: “Partly inherited — like your father — and partly shaped by weight, activity, and food patterns over time.”
  • Prognosis: “Well-managed diabetes lets most people live a full, long life; unmanaged, it damages blood vessels. The big win is catching it now.”
  • Resources: “I’ll give you Diabetes UK’s patient site and a food-diary template — and we’ll set up the diabetes nurse.”

  Phase 2

  • Expectations question: “Before we talk about what to do — given your father, is there anything about this diagnosis you’ve been dreading?”
  • Options: “We have a few paths here — lifestyle change alone for a trial period, lifestyle plus a tablet like metformin, or in some cases going straight to medication. Your numbers are in a range where any of these is reasonable.”

  Phase 3

  • Concrete instruction: “One metformin 500 mg with breakfast and with dinner. Take it with food, not on an empty stomach.”
  • Teach-back: “What will you tell your wife when you get home?”
  • Safety net: “If you get persistent vomiting, or you’re really short of breath — come back right away. Otherwise, the nurse will see you in two weeks, and me again in three months.”

  Compare your sketch with the exemplar. The aim is not identical wording; it is to feel the connective tissue — Phase 1 gave the patient a model (body isn’t handling sugar) that Phase 2 can use (lifestyle change can shift that) and Phase 3 makes specific (metformin with food). A consultation with one phase done well and another skipped is a consultation that fails the patient at the weak link. (MAAS 3.1–3.13)

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  2. Commit-then-compare — The next move

  Goal

  Decide the next move when a consultation is drifting.

  Task

  You are five minutes into the consultation above. You have explained the diagnosis. The patient looks quiet and says: “My dad went blind. He ended up on insulin.”

  Write down your next sentence or two, and one sentence on what phase you are in. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “I hear you — that’s heavy to carry into this diagnosis. Can you tell me what frightens you most about it?”
  • “What you’re describing must make this diagnosis feel different from how it would feel for someone else. Before we go on — is there something specific you’ve been dreading?”

  The move is a step back into Phase 2 — exploring expectations and concerns (3.4). The patient has just told you the most important thing they will tell you in this consultation. Pushing on to treatment options now would mean missing it. The book structure matters, but so does being willing to leave the page open when the patient needs you to. Compare your response with the exemplars. (MAAS 3.4)

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  3. Spot-the-issue — What is this consultation missing?

  Goal

  Diagnose a consultation that looks complete but isn’t.

  Task

  Read this exchange and name the item(s) that have been skipped.

  Physician: So — you have reflux. Acid from your stomach coming up into the tube that connects to your throat. Typical causes are big meals, lying down after eating, being overweight. Most people manage it well with lifestyle changes and occasionally a tablet. I’ll give you a leaflet and a prescription for omeprazole. Twenty milligrams, once a day for four weeks. Any questions?
  Patient: No, I think that’s clear.
  Physician: Great. See you in a month if it’s not better.

  Reveal answer

  Phase 1 is done well — diagnosis, causes, prognosis, resources are all there, structured, and concrete. What is missing is Phase 2 almost entirely: the patient’s expectations were not explored (3.4), options were not offered (3.5), willingness to start a medication was not checked (3.10). And Phase 3 has the prescription but lacks teach-back (3.12) and a proper safety net (3.13 — what warrants earlier return, and how). The consultation reads as complete because information was delivered. But the patient has not been involved in the decision and has no plan for when things go wrong. This is the classic Phase-1-only consultation — and it is the shape adherence studies predict will fail. (Feedback Index: Shared Decision-Making · Safety Netting)

  That completes Chapter 4. You have now worked through the two halves of the consultation — history-taking in Chapters 1 to 3, and presenting solutions in Chapter 4. The next chapters turn to the process skills that carry all of this: structuring the interview, responding to emotion, and making yourself understood.

5Chapter 5. Process Skills

• 5.1Theme 1 — Structuring the consultation

  Structure is not formality — it is cognitive scaffolding that prevents error and makes sure nothing important is missed. Most of its power lives in two places: how the consultation opens, and how it closes. This theme practises both, plus the sequence and signposting that hold the middle together.

  For the skills behind these exercises, see MAAS items A.1–A.8 on this website, and Chapter 5 of the handbook (§ Part I — Scale A) for the reasoning.

  1. Recognition — “Something” or “Anything”?

  Goal

  Recognise the one-word difference that determines whether patients bring up further concerns.

  Task

  You have just heard the patient’s opening concern. You want to secure the rest of the agenda. Which question is most likely to uncover further concerns?

  • A) “Is there anything else?”
  • B) “Is there something else you want to address?”
  • C) “That’s everything, yes?”
  • D) “Anything else quickly?”

  Reveal answer

  B reduces unmet concerns by around 78%. A gets a polite “no” — the word “anything” is easy to dismiss, because it does not presuppose. B uses “something”, which gently assumes there is more, giving the patient permission to raise it. C closes the topic. D signals time pressure — the patient now weighs bothering you against their concern, and most back off. One word does most of the work. (MAAS A.2)

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  2. Recognition — Which sequence is correct?

  Goal

  Recognise the ordering of consultation phases that protects against premature closure.

  Task

  Which sequence reflects the order MAAS recommends for the consultation?

  • A) Agenda → examination → history → solutions
  • B) Exploration of Reasons for Encounter → history-taking → presenting solutions
  • C) History → exploration → solutions → examination
  • D) Solutions → history → exploration

  Reveal answer

  B is the sequence. Exploration first surfaces what the patient has come for and worries about; history-taking then fills in the clinical picture; solutions close the consultation. Breaking the order is how premature closure happens, and premature closure is present in around 80% of diagnostic errors. A student who moves to solutions before the history is done treats a hypothesis rather than a patient. (MAAS A.5, A.6)

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  3. Reformulation — Signpost a transition

  Goal

  Make a transition between consultation phases visible to the patient.

  Task

  You have finished exploring the patient’s reasons for coming. You are about to move into focused history-taking. The current transition: “OK. Any other symptoms?” Rewrite it so the patient knows what is happening.

  Reveal exemplar and feedback

  Exemplar:

  “Thank you for telling me all that. I’d like to ask you some more specific questions now about the symptoms themselves — when they come, what makes them worse or better — and then we’ll look at what might be going on. Is that all right?”

  Compare yours with the exemplar. Notice three moves: acknowledging what has just happened, naming what comes next, and asking permission. Signposting turns an abrupt shift into a collaboration. It takes five extra seconds and reduces the feeling of being interrogated. (MAAS A.3, A.4)

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  4. Spot-the-issue — Treatment before diagnosis

  Goal

  Notice when treatment has been prescribed without explaining the diagnosis first.

  Task

  Read this exchange. What has the physician skipped?

  Physician: Right, so I’m going to start you on omeprazole, twenty milligrams once a day for four weeks. Take it half an hour before breakfast. I’ll see you in a month.
  Patient: Erm … OK. What is it exactly that I’ve got?
  Physician: Acid reflux.
  Patient: Right.

  Reveal answer

  The physician prescribed before explaining, reversing item A.7. The patient had to ask for the diagnosis after the treatment had already been decided. Patients adhere better to treatment they understand; the “why” before the “what” is what creates acceptance. The exchange is also a communication warning sign: when a patient asks the diagnosis at the end, they are telling you they did not understand the start. (MAAS A.7)

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  5. Apply to case — Opening and closing the bookends

  Goal

  Use the two bookends to open and close a single consultation.

  Task

  A new patient walks in. Write one sentence for each of the two bookends:

  • Opening bookend (secure the full agenda at the start): _____
  • Closing bookend (catch anything that surfaced during the visit): _____

  Write both before revealing.

  Reveal exemplars and feedback

  Exemplars:

  • Opening: “What would you like to talk about today? … and is there something else you want to address?”
  • Closing: “We’ve covered X and Y. Is there something else we should discuss before you go?”

  Compare yours with the exemplars. Notice that the opening is not one question but two — the first invites, the second anticipates there is more. The closing names what has been covered before asking, which does two things at once: it helps the patient remember whether anything was unsaid, and it signals that the conversation has been followed. Together, the two bookends cut the rate of missed concerns by more than half. (MAAS A.2, A.8)

• 5.2Theme 2 — Being present: facilitation, ease, authenticity

  Before emotion and before technique, the patient notices whether you are with them. This theme practises the moves that create presence — facilitation, putting at ease, pace, and the quiet honesty that patients call warmth.

  For the skills behind these exercises, see MAAS items B.1, B.7, B.8, B.9, B.10, and B.11 on this website, and Chapter 5 of the handbook (§ Part II — Scale B).

  1. Recognition — What counts as facilitation?

  Goal

  Recognise the small moves that keep the patient talking.

  Task

  A patient has paused mid-sentence, mid-story. Which response is facilitation?

  • A) “OK. Any other symptoms?”
  • B) A nod, attentive silence, and “Go on…”
  • C) “So are you saying you’re depressed?”
  • D) “Let’s move on.”

  Reveal answer

  B is facilitation. It uses three tools at once — nod, silence, and a minimal prompt — and invites the patient to continue in their own words. A changes the topic. C interprets, which cuts the story short and narrows what the patient can say next. D explicitly closes the space. Facilitation is not a filler; it is the move that lets patients tell you the thing they had to work up the courage to say. (MAAS B.1)

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  2. Reformulation — From rushing to pacing

  Goal

  Rewrite a rapid-fire question sequence into pace the patient can match.

  Task

  A physician, running behind, says all in one breath: “OK so how long’s it been going on, what makes it worse, any other symptoms, any past history of this, are you on anything for it?”

  Rewrite this as a slower opening that respects the patient’s processing.

  Reveal exemplar and feedback

  Exemplar:

  “Let’s start at the beginning. When did you first notice this? … (listen) … And what’s it been like since then?”

  Compare yours with the exemplar. One question, a pause, then a follow-up that builds on what was heard. Rapid-fire signals to the patient that you are busy, and patients respond by giving you less — shorter answers, fewer concerns raised, more “fine, thanks.” Patients who feel pace is theirs tell you more, faster, because they trust the conversation. (MAAS B.9)

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  3. Apply to case — Putting a frightened patient at ease

  Goal

  Reduce a patient’s anxiety without dismissing what they are feeling.

  Task

  A 28-year-old woman comes in visibly tearful about a small lump in her breast she found two days ago. You notice her hands are trembling. Write down your first one or two sentences with her. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “I can see this has been frightening. Before we look at anything, let’s just take a moment. Would you like to tell me what you’ve been thinking?”
  • “Thanks for coming in today — that takes courage when you’re worried. Shall I tell you what we’ll do together in this consultation, so you know what to expect?”

  Compare yours with the exemplars. Notice that neither exemplar rushes to reassurance (“most lumps are benign”) — that would feel dismissive before the patient has been heard. Each one instead acknowledges the fear, offers space, and signals that the next few minutes will be held gently. Anxiety impairs recall; reducing it at the start makes everything that follows more useful. (MAAS B.8)

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  4. Spot-the-issue — The filled silence

  Goal

  Notice when a facilitative silence has been filled with a new question instead.

  Task

  Read this exchange. What has the physician done?

  Patient: I’ve been feeling like I’m not quite myself lately … it’s hard to explain … (pauses, looking down)
  Physician: Is it anxiety? Or more a low mood?
  Patient: Erm … I don’t know, really.

  Reveal answer

  The physician filled a silence that was doing work. The patient was finding words for something they had not yet named — three more seconds of quiet might have let them. Offering two labels (anxiety, low mood) closes the space and usually prompts a tentative “I don’t know.” The patient now has to choose between the physician’s options rather than their own experience. Silence is not absence; it is invitation. (MAAS B.1)

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  5. Recognition — Authentic vs. performed warmth

  Goal

  Recognise the difference between verbal-nonverbal congruence and performed warmth.

  Task

  A physician says the words “I’m sorry to hear that” in response to a patient’s distress. Which version is more likely to be received as genuine?

  • A) Said while typing into the computer, eyes on the screen.
  • B) Said after a short pause, with eye contact, and a slight slowing of voice.
  • C) Said quickly with a smile, on the way to the next question.
  • D) Said loudly while reaching for the prescription pad.

  Reveal answer

  B is the only one where the words match the body. In A, C, and D, the words say one thing and the body says another — patients notice this mismatch immediately, even if they could not name it, and it registers as insincerity. Authenticity is not a manner to adopt; it is verbal and non-verbal moving together. Patients can tell when the two are out of step, and the gap undoes the warmth the words were meant to deliver. (MAAS B.10, B.11)

• 5.3Theme 3 — Emotion and difficult moments

  This is the part of the consultation that happens in seconds and stays in the patient’s memory for years. Physicians respond to only about 47% of emotional cues — most are missed, dismissed, or treated as data rather than as moments. This theme practises noticing, naming, and responding. Some of what it teaches can be drilled on paper; much of it will only develop when a real patient cries, looks away, or raises their voice. We name that openly in the closing exercise.

  For the skills behind these exercises, see MAAS items B.2, B.3, B.4, B.5, and B.6 on this website, and Chapter 5 of the handbook (§ 2.3 Responding to Emotion).

  1. Recognition — NURSE in one question

  Goal

  Recognise the NURSE framework in a single empathic response.

  Task

  A patient has just said: “I haven’t slept properly in weeks. My wife is scared something’s seriously wrong.” Which response uses all five NURSE moves?

  • A) “Let’s do some blood tests.”
  • B) “That sounds exhausting. It makes sense she’s worried — you’re both dealing with a lot. I’m here to help us work out what’s going on. Tell me what’s been on your mind.”
  • C) “Most people with insomnia are fine. Try to relax.”
  • D) “How long has it been exactly?”

  Reveal answer

  B uses all five. Name the emotion (“exhausting”), Understand (“makes sense she’s worried”), Respect (“you’re both dealing with a lot”), Support (“I’m here to help us work out”), Explore (“tell me what’s been on your mind”). A and D skip to data-gathering. C dismisses. NURSE is not a script to recite; it is five things to do, in any order. You may not use all of them in every response — but if you never use any of them, the patient does not feel met. (MAAS B.2, B.3, B.4)

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  2. Recognition — What is an emotional cue?

  Goal

  Recognise emotional cues in the three forms they take — verbal, non-verbal, indirect.

  Task

  Which of these patient statements or behaviours is most clearly an indirect cue that something frightens them?

  • A) “I’m worried this is cancer.”
  • B) (Tears in the patient’s eyes as they describe a symptom.)
  • C) “My mother died of this when she was fifty.”
  • D) “I’ve been feeling really anxious.”

  Reveal answer

  C is the indirect cue. The patient has not said “I’m afraid this will happen to me” — but the statement is only relevant in this consultation if that is what they mean. A and D are direct verbal cues. B is non-verbal. Indirect cues are the hardest to catch and often the most important. Missed indirect cues are a main reason physicians respond to less than half of emotional signals — the patient gave you the data, but not in the form the ear is trained for. (MAAS B.2)

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  3. Reformulation — From dismissal to reflection

  Goal

  Rewrite a dismissive response as a reflection of what the patient actually said.

  Task

  A patient has just said, quietly: “I don’t know how I’m going to manage if this keeps going.” A physician responds: “Oh, I’m sure you’ll be fine.” Rewrite the response so it reflects what the patient said, rather than closing it down.

  Reveal exemplars and feedback

  Exemplars:

  • “That sounds really hard. Tell me what’s feeling like the heaviest bit.”
  • “You said you don’t know how you’ll manage. What’s been going through your mind?”
  • “This has been wearing on you. What does a bad day look like at the moment?”

  Compare yours with the exemplars. Each reflects what the patient said before it invites more — the opposite of “I’m sure you’ll be fine.” Reassurance before reflection sounds kind but is experienced as dismissal, because the patient concludes you did not hear them. You have not made anything worse by reflecting; you have made it possible for them to say the next thing. (MAAS B.2)

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  4. Spot-the-issue — The missed cue

  Goal

  Notice an emotional cue that has been stepped over.

  Task

  Read this exchange. What did the physician pass?

  Patient: I’ve been having these headaches … my mother died of a brain tumour when she was forty-two.
  Physician: OK. And when did the headaches start?
  Patient: About three weeks ago.

  Reveal answer

  The physician passed an indirect emotional cue. The patient did not say “I’m afraid I have what my mother had,” but that is what the statement almost certainly means. Moving straight to onset history tells the patient that their fear is not part of the consultation. The rest of the history will be shorter, less detailed, and less honest as a result. A simple reflection — “That’s an important thing to tell me — can you say what’s been on your mind?” — takes ten seconds and reshapes the consultation. (Feedback Index: Emotional Attunement)

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  5. Reflection — what this theme cannot teach

  Goal

  Name what you can work on alone and what requires a real or simulated patient.

  Task

  Take five minutes with these four prompts. Write them down for yourself — there is no answer key.

  1. Name one emotional cue you now feel more confident you could spot in a transcript.
  2. Name one interaction — a crying patient, an angry patient, a patient who deflects everything — that you have not been prepared for by these exercises alone.
  3. What do you expect will only develop through real or simulated encounters?
  4. What would you bring to a simulated-patient session this term?

  Reveal reflection

  This exercise has no answer key. What matters is that you can name, in your own words, the line between what paper can teach and what a real encounter will.

  Emotional responsiveness does not live in a written exercise. You can recognise NURSE on a page, and then freeze when a patient starts crying. You can identify an indirect cue in a transcript, and miss the same cue in the room because of the person’s tone. Responding to aggression (B.5) is a skill almost no one develops without scripted role-play and a debrief. These exercises build the ear; the voice develops elsewhere.

  The honest question to bring to your tutor or simulated-patient session is not “how am I doing?” It is “here is the specific moment I notice I am flinching or missing — can we work on this one?” (MAAS B.2–B.6)

• 5.4Theme 4 — Clear, responsive communication

  Scale C is the craft of information delivery — when to use closed questions, when to make the abstract concrete, how to chunk and summarise, when to stop and check. The themes so far have set the structure and the relationship; this theme is the craft those hold in place.

  For the skills behind these exercises, see MAAS items C.1–C.7 on this website, and Chapter 5 of the handbook (§ Part III — Scale C) for the reasoning.

  1. Recognition — When a closed question is the right move

  Goal

  Recognise where a closed question does useful work rather than narrows the conversation.

  Task

  At which of these moments is a closed question most appropriate?

  • A) Opening the consultation, when you first ask what brings the patient in.
  • B) Exploring emotional impact.
  • C) Confirming a specific clinical detail after the patient has described their symptom — “And has the pain moved anywhere?”
  • D) Trying to understand the patient’s overall story.

  Reveal answer

  C is the right use. A closed question sharpens a detail once the patient has had room to describe their experience. In the other moments — opening, emotion, story — a closed question cuts the conversation short. Closed questions are a scalpel, not a scythe. Used well, they tighten a picture; used early, they prevent one from forming. (MAAS C.1)

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  2. Reformulation — From jargon to plain language

  Goal

  Rewrite a jargon-heavy explanation so a patient without medical training can follow.

  Task

  A physician explains: “You have bilateral lower extremity oedema, likely secondary to venous insufficiency, which is being exacerbated by your antihypertensive regimen.” Rewrite this so the patient hears the same information without needing a dictionary.

  Reveal exemplar and feedback

  Exemplar:

  “Both your legs are holding more fluid than they should — that’s what the swelling is. The veins in your legs aren’t draining fluid back up as well as they used to. One of the blood-pressure tablets you’re on can make this worse, which is why it’s more noticeable now.”

  Compare yours with the exemplar. Notice what was removed (the Latin and the technical chain) and what was added (a mental picture — the veins not draining well). Every rewording replaced a term with a description the patient could hold in mind. Plain language is not dumbing down; it is refusing to hide behind precision. A patient who understands adheres better, remembers more, and returns when something changes. (MAAS C.7)

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  3. Reformulation — Chunking the information

  Goal

  Rewrite a long explanation into small chunks separated by pauses.

  Task

  A physician says, in one continuous stream: “So you’ve got type 2 diabetes, we’re going to start metformin one tablet twice a day with food, you’ll need a blood test every three months, avoid sugary drinks, see the diabetes nurse in two weeks, and if you feel very thirsty or lose weight suddenly come back.” Rewrite this as three chunks, each with a check-in before the next.

  Reveal exemplar and feedback

  Exemplar:

  1. “So, first: you have type 2 diabetes. Is that clear so far? … Good.”
  2. “Next, what we’re going to do about it — one metformin, twice a day, with food. The nurse will see you in two weeks and we’ll do a blood test every three months. Any questions on that bit? … Good.”
  3. “Last — what to watch for: if you get very thirsty, losing weight without trying, or feeling unwell, come back sooner. OK?”

  Compare yours with the exemplar. Notice the structure: a chunk, a check-in, the next chunk. Information delivered in one breath disappears; information delivered in chunks, each one confirmed, sticks. This move alone improves patient recall substantially — especially in older patients and those with lower health literacy. (MAAS C.4, C.5)

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  4. Recognition — An effective summary

  Goal

  Recognise a summary that is doing work, not just repeating what was said.

  Task

  You have finished the history for a patient with chest pain. Which summary most usefully consolidates what has been learned?

  • A) “OK, any other symptoms?”
  • B) “So let me make sure I’ve understood — you’ve had this tight, central chest pain for two weeks, mostly after eating, no radiation, no breathlessness, and it’s getting better since you cut down the late dinners. Is that right?”
  • C) “So chest pain. Let’s examine.”
  • D) “OK, I think we have enough. I’ll prescribe something.”

  Reveal answer

  B is the summary that does work. It names the key features (nature, time, localisation, modifying factors), checks for accuracy (“is that right?”), and gives the patient a chance to correct. A, C, and D are transitions, not summaries. A good summary is diagnostic: it surfaces what you have heard wrong, what you have missed, and what you had under-weighted — before you commit to the next phase of the consultation. (MAAS C.3)

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  5. Apply to case — Teach-back, from Scale C

  Goal

  Use a teach-back check to verify that an explanation has landed.

  Task

  You have just finished explaining the new metformin regimen above. Write the check-in that verifies understanding, without making the patient feel tested. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “I know I covered a lot. What’s your plan when you get home?”
  • “Can you tell me in your own words what you’ll do with the tablets, and when?”
  • “What will you tell your partner about this when they ask?”

  Compare yours with the exemplars. Each one shifts the frame: the patient is being asked to prepare for a real use (going home, explaining to a partner) rather than sit an exam. That frame is what makes teach-back work — the patient speaks freely, and the gaps in your explanation become visible. Scale C teach-back and the Chapter 4 version are the same technique; what matters is the tone that invites rather than tests. (MAAS C.5)

• 5.5Theme 5 — Integration: process supports content

  The three scales do not run one at a time — they run together, continuously, through the whole consultation. This theme practises noticing how they interlock, and what happens when one of them drops.

  For the integrating reasoning, see Chapter 5 of the handbook (§ Part IV — Process Supports Content), and MAAS items A.1–C.7.

  1. Apply to case — Spotting the three scales in a single exchange

  Goal

  Identify the moves from Scale A, Scale B, and Scale C in one short consultation excerpt.

  Task

  Read this opening and identify at least one move from each of the three scales.

  Physician: Good morning — thanks for coming. Before we start, what would you like us to talk about today? … and is there something else you want to address? … Good. I’m going to ask you a bit about the headaches first, then we’ll talk about what might be going on. Is that all right?
  Patient: Yes.
  Physician: So — when did they start?
  Patient: About three weeks ago … around the time my dad went into hospital, actually.
  Physician: I’m sorry to hear that. That must have been a difficult time. Can you say a little about what’s been going on?

  Reveal answer

  Scale A: the bookend opening (“is there something else…”) and the signposted transition (“I’m going to ask you about the headaches first, then…”).

  Scale B: catching the indirect cue (“my dad went into hospital”) and reflecting it (“that must have been a difficult time”).

  Scale C: the closed-then-open move (“when did they start?” → open invitation to say more).

  Compare your list with these. The three scales are never present as labels; they are visible as moves. Expert consultations have small moves from all three almost continuously — the patient does not notice any one of them, but notices the difference between this consultation and one that misses them. (MAAS A.2, A.3, B.2, B.4, C.1)

  ---

  2. Commit-then-compare — The next move when something drops

  Goal

  Decide what to do when you notice one of the three scales has slipped in a running consultation.

  Task

  Mid-consultation, you notice that you have delivered three minutes of unbroken information to a patient without a check-in. The patient looks lost. Write down your next sentence — and name which scale you are correcting. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “Let me pause there for a moment. I’ve just given you quite a bit — is there anything in what I’ve said that I should explain differently?” — correcting Scale C (check understanding, chunking).
  • “Sorry, I’ve been talking at you. What’s been sitting with you most from what I’ve said?” — a mix of Scale B (reading the patient) and Scale C (inviting the patient back in).

  Compare yours with the exemplars. The point is not which words you use but that you notice and correct. Expert consultations are not consultations without slips; they are consultations where slips are caught within ten seconds. A check-in does not undo the first three minutes — it opens the second three. (MAAS C.4, C.5, B.1)

  ---

  3. Spot-the-issue — The process-content mismatch

  Goal

  Notice when the content is right but the process has fallen away.

  Task

  Read this closing. The clinical content is correct. What is missing from the process?

  Physician: So you have gastroenteritis. It’s self-limiting, usually resolves in two to three days. Drink plenty of fluids, bland food, no dairy for a few days. If you get a fever over thirty-nine, persistent vomiting, or blood in the stool, come back. Next. (turns to computer)
  Patient: OK… thanks.

  Reveal answer

  The content is complete — diagnosis, prognosis, self-care, safety net are all there. But the process has dropped almost entirely. No bookend at close (“is there something else?”, Scale A.8). No check-in that the information landed (Scale C, teach-back). No warmth in the closing — the physician turns to the computer before the patient has finished thanking them (Scale B.10, congruence). The patient leaves correctly treated and not feeling cared-for, and in six months will not be able to remember your name or the advice. The three scales do not make up for bad content, but they are what turns correct content into useful content. (MAAS A.8, B.10, C.5)

  That completes Chapter 5. You have now worked through the whole craft of the medical interview — exploring, history-taking, review of systems, presenting solutions, and the process skills that hold it all together. The next chapters turn to how the parts flow into one consultation, and how one consultation sits inside a patient’s longer journey.

6Chapter 6. Integration

• 6.1Theme 1 — The three diagnostic cycles

  Inside the consultation, the diagnostic work runs through three nested cycles: Complaint (the patient’s reasons for coming), Story (the patient’s narrative, followed with the heuristics), and Check (what the patient wouldn’t know to mention — red flags, systematic review). The sequence matters: understand before you investigate, listen before you interrogate. At any moment you should be able to ask yourself which cycle am I in? This theme practises naming the cycles, keeping their order, and not confusing them with the consultation’s outer phases.

  For the reasoning, see Chapter 6 of the handbook (§ 4 — The Three Diagnostic Cycles).

  1. Recognition — Which cycle is this?

  Goal

  Identify which cycle a given question belongs to.

  Task

  Near the end of taking a history, a physician asks: “Before we finish — any weight loss, fevers, or night sweats recently?” Which cycle is this?

  • A) Cycle 1 — Complaint (the patient’s reasons)
  • B) Cycle 2 — Story (the patient’s narrative)
  • C) Cycle 3 — Check (the physician’s review)
  • D) None — this belongs to the frame

  Reveal answer

  C — Cycle 3, the Check. These are questions the patient would not know to raise on their own; the physician adds them from medical knowledge, screening for what might be hiding behind the obvious complaint. A would sound like “what made you decide to come in today?”; B follows the patient’s own account with the heuristics (“when did it start, what’s it like?”). The Check belongs after the story, not before it — lead with it and a conversation turns into an interrogation. (MAAS — diagnostic cycles)

  ---

  2. Commit-then-compare — The opening move

  Goal

  Choose the first move when a patient opens with a request rather than a concern.

  Task

  Mr. Lee sits down and says: “I just came to get my blood pressure checked, doctor.” Write your next move, and note which cycle you are in — and which one you must not skip ahead to. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  “Of course, I’ll do that — before I do, is there anything in particular that’s been on your mind?”

  You are at the start of Cycle 1 (Complaint). The move is to open up why he came, not to jump to taking a reading (Cycle 2) or to run through cardiovascular risk factors (Cycle 3). In Mr. Lee’s real consultation it was the Complaint cycle that surfaced the chest pain hiding behind “blood pressure”. Cycle 1 before Cycle 2: understand before you investigate. (MAAS A.5, Scale 1)

  ---

  3. Spot-the-issue — Leading with the Check

  Goal

  Notice when the physician has jumped to Cycle 3 before the patient has told their story.

  Task

  A patient comes in with a week of headaches. The physician opens: “Right — any visual changes? Any weakness? Any fever? Any nausea? Any weight loss?” What has gone wrong?

  Reveal answer

  The physician has jumped straight to Cycle 3 (the Check) — firing systematic red-flag questions before the patient has said why they came (Cycle 1) or told their own story (Cycle 2). The medicine may be thorough, but the patient never gets to name what they noticed or what they fear, and the consultation has become an interrogation. Listen before you interrogate: Cycle 2 before Cycle 3. (MAAS A.5, Feedback Index: Sequence)

  ---

  4. Recognition — Two triads, not one

  Goal

  Keep the three cycles distinct from the three consultation phases.

  Task

  A learner says: “I’m in the History-Taking phase, so I must be in Cycle 2.” True or false — and why?

  • A) True — the phases and the cycles are the same thing under two names.
  • B) False — the phases are the consultation’s outer movement; the cycles are the smaller diagnostic loop nested inside them.

  Reveal answer

  B. The three phases (Reasons for Encounter, History-Taking, Presenting Solutions) are the consultation’s larger movement — the score. The three cycles (Complaint, Story, Check) are the rhythm of the diagnostic work inside them — the beat. You can run all three cycles within a single phase, and the same phase can hold more than one. Naming which cycle you are in keeps you oriented even when you are deep inside one phase. (MAAS — phases and cycles)

  ---

  5. Apply to case — Mark the cycles

  Goal

  Read a short consultation and mark where each cycle begins.

  Task

  Read the exchange below. Where does each of the three cycles start?

  Patient: I’ve come about these dizzy spells.
  Physician: Tell me about them — when do they happen?
  Patient: When I stand up too fast, mostly. The last few weeks.
  Physician: And have you had any blackouts, chest pain, or palpitations with them?

  Reveal answer and feedback

  Cycle 1 (Complaint): “I’ve come about these dizzy spells” — the patient naming why they came.

  Cycle 2 (Story): “Tell me about them — when do they happen?” — following the narrative with a time-pattern heuristic.

  Cycle 3 (Check): “any blackouts, chest pain, or palpitations?” — the physician adding what the patient wouldn’t know to mention.

  All three, in sequence, in four lines. That is the rhythm a fluent consultation keeps without naming it aloud. (MAAS — diagnostic cycles)

  Theme 2 — The economy of attention

  Every patient brings a finite amount of attention, energy and emotional capacity into the room, and each phase of the consultation spends some of it. What you spend in history-taking is no longer available when you explain the diagnosis. The skill is not to do less of everything — it is to build the consultation so the patient still has something left when you reach the part that asks them to act. This theme practises spotting where attention is overspent and protecting it.

  For the reasoning, see Chapter 6 of the handbook (§ 5 — Each Phase Costs Something).

  1. Recognition — The finite resource

  Goal

  Recognise the patient’s attention as a budget that gets spent.

  Task

  A physician takes an unusually thorough history, then explains the plan clearly. At the very end the patient asks: “Sorry — was that tablet once or twice a day?” What does this most likely show?

  • A) The patient wasn’t paying attention.
  • B) The explanation was unclear.
  • C) The patient’s attention was used up before the explanation arrived.
  • D) The history was too short.

  Reveal answer

  C. The patient was full. Each question during history-taking spent a little of a finite budget; by the time the explanation arrived, almost nothing was left. The fix is not to do less of everything, but to build the consultation so the patient still has capacity when you reach the part that asks them to act. (MAAS — economy of attention)

  ---

  2. Commit-then-compare — Spending the budget

  Goal

  Protect the explanation when the history has already run long.

  Task

  A case is complex and the history runs long. Write down one thing you would change in the way you present the solution, so the patient can still hold on to it. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • Chunk it — one idea at a time, checking understanding between each.
  • Lead with the single most important action, before anything optional.
  • Write the key instruction down, so it doesn’t rely on memory.
  • Defer non-essential detail to a leaflet or the next visit.

  Compare your answer. After a long history the patient’s capacity is low, so protect the explanation by shrinking and sequencing it — not by adding more. (MAAS A.7)

  ---

  3. Spot-the-issue — The door-handle moment

  Goal

  See that the loaded concern raised at the door is structural — and which earlier move prevents it.

  Task

  The physician asks the proper closing question — “have we covered everything you wanted to discuss?” — and the patient, hand on the door, says: “Well, there is one other thing…” What earlier move would have made this less likely?

  Reveal answer

  Surfacing the full agenda at the start — “what’s brought you in today — is it one concern or several?” (A.2 / A.3). The door-handle moment is structural, not a failure of the closing question: loaded concerns often surface only as the pressure of the interview lifts. Agenda-setting at the start and the closing question work as a pair. (MAAS A.2, A.3, A.8, Feedback Index: Agenda)

  ---

  4. Reformulation — Signpost a transition

  Goal

  Use a transition that orients the patient and frees their attention.

  Task

  A physician moves from history to examination with: “Let me look at you now.” Rewrite it so the patient knows what is happening and what comes next. Then reveal.

  Reveal exemplar and feedback

  “Thanks — that gives me a clear picture. I’d like to examine you now, and then we’ll sit down and talk through what I think is going on and what to do. Is that all right?”

  Compare yours. A signposted transition tells the patient where they are and what is coming, which lowers anxiety and frees attention for the part that matters. Five seconds, reliable payoff. (MAAS A.3)

  ---

  5. Apply to case — Where did the attention go?

  Goal

  Find where attention was overspent, and what to trim.

  Task

  Read this outline. Where was the patient’s attention overspent, and what would you change?

  A twenty-minute consultation for a simple sore throat: twelve minutes of detailed history, including a full social history, then a hurried two-minute explanation of self-care and when to seek help.

  Reveal answer and feedback

  The history was exhaustive for a straightforward complaint, and the part the patient must act on — the self-care and the safety-net — got the leftovers. Trim the history to what this case needs, and give the advice more room and a check-back (“just so I’m sure it landed — when would you come back?”). Depth isn’t free; spend it where it changes what the patient does. (MAAS — economy of attention)

  Theme 3 — Recovery in consultation

  Every physician loses the thread sometimes — you forget to explore an emotion, rush to a diagnosis, or realise you have stopped listening. This is not a sign of incompetence; it happens to everyone, and the skill is not avoiding it but finding your way back. The moves that help are small and learnable: return to the structure, summarise what you know, name the difficulty if you need to, and repair what you missed. This theme practises those moves — and the three responses that quietly make things worse.

  For the reasoning, see Chapter 6 of the handbook (§ 8 — When It Falls Apart).

  1. Recognition — The move that helps

  Goal

  Choose the response most likely to help when you have lost track mid-consultation.

  Task

  Mid-consultation you realise you are not sure what you have covered or where you are. Which move is most likely to help you regain your footing?

  • A) Speed up to get through the rest before the patient notices.
  • B) Summarise aloud what you understand so far.
  • C) Carry on and hope the thread comes back.
  • D) Drop the structure — it clearly isn’t working today.

  Reveal answer

  B. Summarising aloud buys you time while it re-orients both you and the patient, and it shows you are listening. A, C, and D are the three classic worse-moves — speeding up, pretending, and abandoning structure. The structure did not fail; you lost track of it, and returning to it is exactly what catches you when intuition slips. (MAAS A.4 — ordering main findings)

  ---

  2. Reformulation — Two lines for finding your way back

  Goal

  Have ready-made phrasing for re-orienting yourself out loud.

  Task

  You are lost. Write two sentences: one that summarises to regain orientation, and one that openly names that you want to slow down. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • Summarise: “Let me just check I’ve understood what you’ve told me so far — you’ve had…”
  • Name it: “I want to slow down here for a moment — this part is important.”

  Compare yours with the exemplars. The summary re-orients both of you and signals that you are listening; naming the need to slow down reads as care, not weakness. Patients respect honesty, and pretending you are not struggling is more visible than you think. (MAAS A.4, C)

  ---

  3. Spot-the-issue — The move that makes it worse

  Goal

  Notice the worse-move of speeding up under pressure.

  Task

  A physician has lost the thread on a complex history. Feeling the minutes pass, they begin asking questions faster and stop pausing for the answers. What is the error?

  Reveal answer

  They are speeding up when they should slow down. Time pressure makes the loss worse, not better — the feeling of being rushed is itself the signal to pause, not to accelerate. The faster pace also tells the patient that something is wrong while giving them no room to help. The repair is the opposite move: stop, summarise, and let the pace drop. (MAAS A — pacing, Feedback Index: Pacing)

  ---

  4. Commit-then-compare — The repair

  Goal

  Circle back to something you moved past earlier.

  Task

  Twenty minutes in, you realise that earlier the patient mentioned, almost in passing, that their father had just died — and you moved straight on. You are now near the end of the consultation. Write the sentence you would use to circle back. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  “Earlier you mentioned your father. I didn’t ask more about him at the time — can you tell me what’s been on your mind?”

  Compare yours with the exemplar. It is never too late within the consultation to return to something you missed; naming it openly turns an omission into a repair, and circling back to a loaded cue often opens exactly what the patient most needed to say. (MAAS B — responding to cues)

  ---

  5. Apply to case — The wrong knee

  Goal

  Recover from a visible slip without losing the patient.

  Task

  Twelve minutes into a consultation about knee pain, you realise you have been asking about the wrong knee for the last two questions. Your face gets warm. What do you do — and what do you avoid?

  Reveal answer and feedback

  Do: name and repair simply — “Sorry, let me make sure I’ve got this right — which knee is it that’s troubling you?” — then summarise to get back on track.

  Avoid: pretending you are not flustered and running the consultation in your head while the room goes quiet. The patient almost never minds the slip itself; what they feel is the disconnection if you stop listening while you privately recover. Return to structure, repair, and move on. (MAAS — recovery)

  Theme 4 — Flow, and why it protects patient and physician

  Flow is the condition under which a consultation is both effective for the patient and sustainable for you. You cannot drill flow directly — it emerges once the cycles, the economy of attention and steady recovery become second nature. What you can do is learn to recognise its conditions, see what breaks it, and reflect on what it costs and what it protects. This theme closes the chapter on that note.

  For the reasoning, see Chapter 6 of the handbook (§ 3 — What Flow Is · § 9 — The Long Shadow · § 10 — From Conscious to Flow).

  1. Recognition — Flow’s conditions in MAAS terms

  Goal

  Connect the research on effective consultations to the MAAS scales.

  Task

  Mauksch and colleagues found three things that, present together, make a consultation both effective and efficient: rapport, up-front agenda-setting, and acknowledging emotional cues. Which MAAS scale does up-front agenda-setting belong to?

  • A) Scale B (Interpersonal)
  • B) Scale A (Structuring) — especially A.2 and A.3
  • C) Scale 2 (History-Taking)
  • D) Scale C (Communication)

  Reveal answer

  B. Up-front agenda-setting is Scale A (Structuring), particularly A.2 and A.3. Rapport and acknowledging cues are both Scale B (Interpersonal). Two independent research traditions — Csikszentmihalyi’s work on flow and Mauksch’s communication model — arrive at much the same picture of what an effective encounter needs, and it maps closely onto the MAAS scales. (MAAS A.2, A.3, B)

  ---

  2. Apply to case — The ending answers the beginning

  Goal

  See the coherence that flow produces — the close answering the opening.

  Task

  Earlier, Mr. Lee told you two things: that his chest pressure “comes on when I walk uphill, stops if I rest”, and that he feared it was his heart, like his father. Read his explanation. Which earlier moment does each part answer?

  “When you walk uphill, your heart has to work harder and needs more blood; these arteries have got tighter, so they can’t deliver enough — that’s the pressure. It is your heart — but a different situation from your father’s; we caught it before any damage.”

  Reveal answer

  “When you walk uphill… that’s the pressure” answers the exertional pattern from History-Taking. “A different situation from your father’s” answers the fear named in Reasons for Encounter. A flowing consultation is coherent — the close answers the opening — and that coherence is what the patient experiences as “this doctor is with me.” (MAAS Scale 3, 3.1)

  ---

  3. Spot-the-issue — When flow breaks

  Goal

  Name the broken flow condition, and see who pays for it.

  Task

  Mid-consultation the phone rings. The physician takes a call about a lab result, hangs up, and asks the patient to repeat what she was saying. She does, with less energy than before. Which flow condition broke — and who pays?

  Reveal answer

  Undivided attention broke; the interruption fragmented the encounter. Both people pay: the patient’s concern shrinks and she discloses less, and the physician loses the thread, so the rest of the consultation is harder and more draining. Fragmentation repeated over years is the daily texture of burnout; flow is its opposite, and it protects both people in the room. (MAAS — flow and continuity)

  ---

  4. Reflection — Flow, and the long view

  Goal

  Name flow when you have felt it — and what it protects.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Think of a consultation, real or observed, that flowed. Which of flow’s conditions were present — clear goals, real-time feedback, undivided attention, a challenge matched to your skill?
  2. Think of one that dragged or fragmented. What was missing?
  3. The same skills that make a patient feel cared for are the ones that keep you wanting to walk into the room years from now. Name one habit you want to build that serves both.

  Reveal reflection

  This exercise has no answer key. Flow is not a technique you add — it is what the cycles, the economy of attention and steady recovery produce once they become second nature. Noticing it when it happens, and noticing what breaks it, is how you build toward it.

  And it is not only for the patient: the consultation that flows is the one that, repeated across a career, sustains you rather than wears you down. (MAAS — from conscious to flow)

  That completes Chapter 6. You have now worked through the whole of a single consultation — the diagnostic cycles that drive it, the attention it spends, what to do when the thread breaks, and the flow that good consultations produce for patient and physician alike. The remaining chapters widen the lens: how a consultation sits inside a patient’s longer journey, how context shapes the interview, and how the skills you have built here become part of a professional life.

• 6.2Theme 2 — The economy of attention

  Every patient brings a finite amount of attention, energy and emotional capacity into the room, and each phase of the consultation spends some of it. What you spend in history-taking is no longer available when you explain the diagnosis. The skill is not to do less of everything — it is to build the consultation so the patient still has something left when you reach the part that asks them to act. This theme practises spotting where attention is overspent and protecting it.

  For the reasoning, see Chapter 6 of the handbook (§ 5 — Each Phase Costs Something).

  1. Recognition — The finite resource

  Goal

  Recognise the patient’s attention as a budget that gets spent.

  Task

  A physician takes an unusually thorough history, then explains the plan clearly. At the very end the patient asks: “Sorry — was that tablet once or twice a day?” What does this most likely show?

  • A) The patient wasn’t paying attention.
  • B) The explanation was unclear.
  • C) The patient’s attention was used up before the explanation arrived.
  • D) The history was too short.

  Reveal answer

  C. The patient was full. Each question during history-taking spent a little of a finite budget; by the time the explanation arrived, almost nothing was left. The fix is not to do less of everything, but to build the consultation so the patient still has capacity when you reach the part that asks them to act. (MAAS — economy of attention)

  ---

  2. Commit-then-compare — Spending the budget

  Goal

  Protect the explanation when the history has already run long.

  Task

  A case is complex and the history runs long. Write down one thing you would change in the way you present the solution, so the patient can still hold on to it. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • Chunk it — one idea at a time, checking understanding between each.
  • Lead with the single most important action, before anything optional.
  • Write the key instruction down, so it doesn’t rely on memory.
  • Defer non-essential detail to a leaflet or the next visit.

  Compare your answer. After a long history the patient’s capacity is low, so protect the explanation by shrinking and sequencing it — not by adding more. (MAAS A.7)

  ---

  3. Spot-the-issue — The door-handle moment

  Goal

  See that the loaded concern raised at the door is structural — and which earlier move prevents it.

  Task

  The physician asks the proper closing question — “have we covered everything you wanted to discuss?” — and the patient, hand on the door, says: “Well, there is one other thing…” What earlier move would have made this less likely?

  Reveal answer

  Surfacing the full agenda at the start — “what’s brought you in today — is it one concern or several?” (A.2 / A.3). The door-handle moment is structural, not a failure of the closing question: loaded concerns often surface only as the pressure of the interview lifts. Agenda-setting at the start and the closing question work as a pair. (MAAS A.2, A.3, A.8, Feedback Index: Agenda)

  ---

  4. Reformulation — Signpost a transition

  Goal

  Use a transition that orients the patient and frees their attention.

  Task

  A physician moves from history to examination with: “Let me look at you now.” Rewrite it so the patient knows what is happening and what comes next. Then reveal.

  Reveal exemplar and feedback

  “Thanks — that gives me a clear picture. I’d like to examine you now, and then we’ll sit down and talk through what I think is going on and what to do. Is that all right?”

  Compare yours. A signposted transition tells the patient where they are and what is coming, which lowers anxiety and frees attention for the part that matters. Five seconds, reliable payoff. (MAAS A.3)

  ---

  5. Apply to case — Where did the attention go?

  Goal

  Find where attention was overspent, and what to trim.

  Task

  Read this outline. Where was the patient’s attention overspent, and what would you change?

  A twenty-minute consultation for a simple sore throat: twelve minutes of detailed history, including a full social history, then a hurried two-minute explanation of self-care and when to seek help.

  Reveal answer and feedback

  The history was exhaustive for a straightforward complaint, and the part the patient must act on — the self-care and the safety-net — got the leftovers. Trim the history to what this case needs, and give the advice more room and a check-back (“just so I’m sure it landed — when would you come back?”). Depth isn’t free; spend it where it changes what the patient does. (MAAS — economy of attention)

  Theme 3 — Recovery in consultation

  Every physician loses the thread sometimes — you forget to explore an emotion, rush to a diagnosis, or realise you have stopped listening. This is not a sign of incompetence; it happens to everyone, and the skill is not avoiding it but finding your way back. The moves that help are small and learnable: return to the structure, summarise what you know, name the difficulty if you need to, and repair what you missed. This theme practises those moves — and the three responses that quietly make things worse.

  For the reasoning, see Chapter 6 of the handbook (§ 8 — When It Falls Apart).

  1. Recognition — The move that helps

  Goal

  Choose the response most likely to help when you have lost track mid-consultation.

  Task

  Mid-consultation you realise you are not sure what you have covered or where you are. Which move is most likely to help you regain your footing?

  • A) Speed up to get through the rest before the patient notices.
  • B) Summarise aloud what you understand so far.
  • C) Carry on and hope the thread comes back.
  • D) Drop the structure — it clearly isn’t working today.

  Reveal answer

  ---

  2. Reformulation — Two lines for finding your way back

  Goal

  Have ready-made phrasing for re-orienting yourself out loud.

  Task

  You are lost. Write two sentences: one that summarises to regain orientation, and one that openly names that you want to slow down. Then reveal.

  Reveal exemplars and feedback

  ---

  3. Spot-the-issue — The move that makes it worse

  Goal

  Notice the worse-move of speeding up under pressure.

  Task

  A physician has lost the thread on a complex history. Feeling the minutes pass, they begin asking questions faster and stop pausing for the answers. What is the error?

  Reveal answer

  ---

  4. Commit-then-compare — The repair

  Goal

  Circle back to something you moved past earlier.

  Task

  Twenty minutes in, you realise that earlier the patient mentioned, almost in passing, that their father had just died — and you moved straight on. You are now near the end of the consultation. Write the sentence you would use to circle back. Then reveal.

  Reveal exemplar and feedback

  ---

  5. Apply to case — The wrong knee

  Goal

  Recover from a visible slip without losing the patient.

  Task

  Twelve minutes into a consultation about knee pain, you realise you have been asking about the wrong knee for the last two questions. Your face gets warm. What do you do — and what do you avoid?

  Reveal answer and feedback

  Theme 4 — Flow, and why it protects patient and physician

  Flow is the condition under which a consultation is both effective for the patient and sustainable for you. You cannot drill flow directly — it emerges once the cycles, the economy of attention and steady recovery become second nature. What you can do is learn to recognise its conditions, see what breaks it, and reflect on what it costs and what it protects. This theme closes the chapter on that note.

  For the reasoning, see Chapter 6 of the handbook (§ 3 — What Flow Is · § 9 — The Long Shadow · § 10 — From Conscious to Flow).

  1. Recognition — Flow’s conditions in MAAS terms

  Goal

  Connect the research on effective consultations to the MAAS scales.

  Task

  Mauksch and colleagues found three things that, present together, make a consultation both effective and efficient: rapport, up-front agenda-setting, and acknowledging emotional cues. Which MAAS scale does up-front agenda-setting belong to?

  • A) Scale B (Interpersonal)
  • B) Scale A (Structuring) — especially A.2 and A.3
  • C) Scale 2 (History-Taking)
  • D) Scale C (Communication)

  Reveal answer

  ---

  2. Apply to case — The ending answers the beginning

  Goal

  See the coherence that flow produces — the close answering the opening.

  Task

  Earlier, Mr. Lee told you two things: that his chest pressure “comes on when I walk uphill, stops if I rest”, and that he feared it was his heart, like his father. Read his explanation. Which earlier moment does each part answer?

  “When you walk uphill, your heart has to work harder and needs more blood; these arteries have got tighter, so they can’t deliver enough — that’s the pressure. It is your heart — but a different situation from your father’s; we caught it before any damage.”

  Reveal answer

  ---

  3. Spot-the-issue — When flow breaks

  Goal

  Name the broken flow condition, and see who pays for it.

  Task

  Mid-consultation the phone rings. The physician takes a call about a lab result, hangs up, and asks the patient to repeat what she was saying. She does, with less energy than before. Which flow condition broke — and who pays?

  Reveal answer

  ---

  4. Reflection — Flow, and the long view

  Goal

  Name flow when you have felt it — and what it protects.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Think of a consultation, real or observed, that flowed. Which of flow’s conditions were present — clear goals, real-time feedback, undivided attention, a challenge matched to your skill?
  2. Think of one that dragged or fragmented. What was missing?
  3. The same skills that make a patient feel cared for are the ones that keep you wanting to walk into the room years from now. Name one habit you want to build that serves both.

  Reveal reflection

  That completes Chapter 6. You have now worked through the whole of a single consultation — the diagnostic cycles that drive it, the attention it spends, what to do when the thread breaks, and the flow that good consultations produce for patient and physician alike. The remaining chapters widen the lens: how a consultation sits inside a patient’s longer journey, how context shapes the interview, and how the skills you have built here become part of a professional life.

• 6.3Theme 3 — Recovery in consultation

  Every physician loses the thread sometimes — you forget to explore an emotion, rush to a diagnosis, or realise you have stopped listening. This is not a sign of incompetence; it happens to everyone, and the skill is not avoiding it but finding your way back. The moves that help are small and learnable: return to the structure, summarise what you know, name the difficulty if you need to, and repair what you missed. This theme practises those moves — and the three responses that quietly make things worse.

  For the reasoning, see Chapter 6 of the handbook (§ 8 — When It Falls Apart).

  1. Recognition — The move that helps

  Goal

  Choose the response most likely to help when you have lost track mid-consultation.

  Task

  Mid-consultation you realise you are not sure what you have covered or where you are. Which move is most likely to help you regain your footing?

  • A) Speed up to get through the rest before the patient notices.
  • B) Summarise aloud what you understand so far.
  • C) Carry on and hope the thread comes back.
  • D) Drop the structure — it clearly isn’t working today.

  Reveal answer

  B. Summarising aloud buys you time while it re-orients both you and the patient, and it shows you are listening. A, C, and D are the three classic worse-moves — speeding up, pretending, and abandoning structure. The structure did not fail; you lost track of it, and returning to it is exactly what catches you when intuition slips. (MAAS A.4 — ordering main findings)

  ---

  2. Reformulation — Two lines for finding your way back

  Goal

  Have ready-made phrasing for re-orienting yourself out loud.

  Task

  You are lost. Write two sentences: one that summarises to regain orientation, and one that openly names that you want to slow down. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • Summarise: “Let me just check I’ve understood what you’ve told me so far — you’ve had…”
  • Name it: “I want to slow down here for a moment — this part is important.”

  Compare yours with the exemplars. The summary re-orients both of you and signals that you are listening; naming the need to slow down reads as care, not weakness. Patients respect honesty, and pretending you are not struggling is more visible than you think. (MAAS A.4, C)

  ---

  3. Spot-the-issue — The move that makes it worse

  Goal

  Notice the worse-move of speeding up under pressure.

  Task

  A physician has lost the thread on a complex history. Feeling the minutes pass, they begin asking questions faster and stop pausing for the answers. What is the error?

  Reveal answer

  They are speeding up when they should slow down. Time pressure makes the loss worse, not better — the feeling of being rushed is itself the signal to pause, not to accelerate. The faster pace also tells the patient that something is wrong while giving them no room to help. The repair is the opposite move: stop, summarise, and let the pace drop. (MAAS A — pacing, Feedback Index: Pacing)

  ---

  4. Commit-then-compare — The repair

  Goal

  Circle back to something you moved past earlier.

  Task

  Twenty minutes in, you realise that earlier the patient mentioned, almost in passing, that their father had just died — and you moved straight on. You are now near the end of the consultation. Write the sentence you would use to circle back. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  “Earlier you mentioned your father. I didn’t ask more about him at the time — can you tell me what’s been on your mind?”

  Compare yours with the exemplar. It is never too late within the consultation to return to something you missed; naming it openly turns an omission into a repair, and circling back to a loaded cue often opens exactly what the patient most needed to say. (MAAS B — responding to cues)

  ---

  5. Apply to case — The wrong knee

  Goal

  Recover from a visible slip without losing the patient.

  Task

  Twelve minutes into a consultation about knee pain, you realise you have been asking about the wrong knee for the last two questions. Your face gets warm. What do you do — and what do you avoid?

  Reveal answer and feedback

  Do: name and repair simply — “Sorry, let me make sure I’ve got this right — which knee is it that’s troubling you?” — then summarise to get back on track.

  Avoid: pretending you are not flustered and running the consultation in your head while the room goes quiet. The patient almost never minds the slip itself; what they feel is the disconnection if you stop listening while you privately recover. Return to structure, repair, and move on. (MAAS — recovery)

  Theme 4 — Flow, and why it protects patient and physician

  Flow is the condition under which a consultation is both effective for the patient and sustainable for you. You cannot drill flow directly — it emerges once the cycles, the economy of attention and steady recovery become second nature. What you can do is learn to recognise its conditions, see what breaks it, and reflect on what it costs and what it protects. This theme closes the chapter on that note.

  For the reasoning, see Chapter 6 of the handbook (§ 3 — What Flow Is · § 9 — The Long Shadow · § 10 — From Conscious to Flow).

  1. Recognition — Flow’s conditions in MAAS terms

  Goal

  Connect the research on effective consultations to the MAAS scales.

  Task

  Mauksch and colleagues found three things that, present together, make a consultation both effective and efficient: rapport, up-front agenda-setting, and acknowledging emotional cues. Which MAAS scale does up-front agenda-setting belong to?

  • A) Scale B (Interpersonal)
  • B) Scale A (Structuring) — especially A.2 and A.3
  • C) Scale 2 (History-Taking)
  • D) Scale C (Communication)

  Reveal answer

  ---

  2. Apply to case — The ending answers the beginning

  Goal

  See the coherence that flow produces — the close answering the opening.

  Task

  Earlier, Mr. Lee told you two things: that his chest pressure “comes on when I walk uphill, stops if I rest”, and that he feared it was his heart, like his father. Read his explanation. Which earlier moment does each part answer?

  “When you walk uphill, your heart has to work harder and needs more blood; these arteries have got tighter, so they can’t deliver enough — that’s the pressure. It is your heart — but a different situation from your father’s; we caught it before any damage.”

  Reveal answer

  ---

  3. Spot-the-issue — When flow breaks

  Goal

  Name the broken flow condition, and see who pays for it.

  Task

  Mid-consultation the phone rings. The physician takes a call about a lab result, hangs up, and asks the patient to repeat what she was saying. She does, with less energy than before. Which flow condition broke — and who pays?

  Reveal answer

  ---

  4. Reflection — Flow, and the long view

  Goal

  Name flow when you have felt it — and what it protects.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Think of a consultation, real or observed, that flowed. Which of flow’s conditions were present — clear goals, real-time feedback, undivided attention, a challenge matched to your skill?
  2. Think of one that dragged or fragmented. What was missing?
  3. The same skills that make a patient feel cared for are the ones that keep you wanting to walk into the room years from now. Name one habit you want to build that serves both.

  Reveal reflection

  That completes Chapter 6. You have now worked through the whole of a single consultation — the diagnostic cycles that drive it, the attention it spends, what to do when the thread breaks, and the flow that good consultations produce for patient and physician alike. The remaining chapters widen the lens: how a consultation sits inside a patient’s longer journey, how context shapes the interview, and how the skills you have built here become part of a professional life.

• 6.4Theme 4 — Flow, and why it protects patient and physician

  Flow is the condition under which a consultation is both effective for the patient and sustainable for you. You cannot drill flow directly — it emerges once the cycles, the economy of attention and steady recovery become second nature. What you can do is learn to recognise its conditions, see what breaks it, and reflect on what it costs and what it protects. This theme closes the chapter on that note.

  For the reasoning, see Chapter 6 of the handbook (§ 3 — What Flow Is · § 9 — The Long Shadow · § 10 — From Conscious to Flow).

  1. Recognition — Flow’s conditions in MAAS terms

  Goal

  Connect the research on effective consultations to the MAAS scales.

  Task

  Mauksch and colleagues found three things that, present together, make a consultation both effective and efficient: rapport, up-front agenda-setting, and acknowledging emotional cues. Which MAAS scale does up-front agenda-setting belong to?

  • A) Scale B (Interpersonal)
  • B) Scale A (Structuring) — especially A.2 and A.3
  • C) Scale 2 (History-Taking)
  • D) Scale C (Communication)

  Reveal answer

  B. Up-front agenda-setting is Scale A (Structuring), particularly A.2 and A.3. Rapport and acknowledging cues are both Scale B (Interpersonal). Two independent research traditions — Csikszentmihalyi’s work on flow and Mauksch’s communication model — arrive at much the same picture of what an effective encounter needs, and it maps closely onto the MAAS scales. (MAAS A.2, A.3, B)

  ---

  2. Apply to case — The ending answers the beginning

  Goal

  See the coherence that flow produces — the close answering the opening.

  Task

  Earlier, Mr. Lee told you two things: that his chest pressure “comes on when I walk uphill, stops if I rest”, and that he feared it was his heart, like his father. Read his explanation. Which earlier moment does each part answer?

  “When you walk uphill, your heart has to work harder and needs more blood; these arteries have got tighter, so they can’t deliver enough — that’s the pressure. It is your heart — but a different situation from your father’s; we caught it before any damage.”

  Reveal answer

  “When you walk uphill… that’s the pressure” answers the exertional pattern from History-Taking. “A different situation from your father’s” answers the fear named in Reasons for Encounter. A flowing consultation is coherent — the close answers the opening — and that coherence is what the patient experiences as “this doctor is with me.” (MAAS Scale 3, 3.1)

  ---

  3. Spot-the-issue — When flow breaks

  Goal

  Name the broken flow condition, and see who pays for it.

  Task

  Mid-consultation the phone rings. The physician takes a call about a lab result, hangs up, and asks the patient to repeat what she was saying. She does, with less energy than before. Which flow condition broke — and who pays?

  Reveal answer

  Undivided attention broke; the interruption fragmented the encounter. Both people pay: the patient’s concern shrinks and she discloses less, and the physician loses the thread, so the rest of the consultation is harder and more draining. Fragmentation repeated over years is the daily texture of burnout; flow is its opposite, and it protects both people in the room. (MAAS — flow and continuity)

  ---

  4. Reflection — Flow, and the long view

  Goal

  Name flow when you have felt it — and what it protects.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Think of a consultation, real or observed, that flowed. Which of flow’s conditions were present — clear goals, real-time feedback, undivided attention, a challenge matched to your skill?
  2. Think of one that dragged or fragmented. What was missing?
  3. The same skills that make a patient feel cared for are the ones that keep you wanting to walk into the room years from now. Name one habit you want to build that serves both.

  Reveal reflection

  This exercise has no answer key. Flow is not a technique you add — it is what the cycles, the economy of attention and steady recovery produce once they become second nature. Noticing it when it happens, and noticing what breaks it, is how you build toward it.

  And it is not only for the patient: the consultation that flows is the one that, repeated across a career, sustains you rather than wears you down. (MAAS — from conscious to flow)

  That completes Chapter 6. You have now worked through the whole of a single consultation — the diagnostic cycles that drive it, the attention it spends, what to do when the thread breaks, and the flow that good consultations produce for patient and physician alike. The remaining chapters widen the lens: how a consultation sits inside a patient’s longer journey, how context shapes the interview, and how the skills you have built here become part of a professional life.

7Chapter 7. The Patient Journey

• 7.1Theme 1 — Eliciting and tracking goals

  A journey has a direction: the thing the patient is trying to get back to. Goal-oriented care makes that explicit — a small shift from “what’s the matter?” to “what matters to you?” The good news is that you already have the raw material. In Chapter 2 you learned that intensity in MAAS is not a number but functional impact — what the symptom stops the patient doing. The goal is that same functional loss, read forwards: what they want to do again. This theme practises naming the goal and tracking it — by function, not by a scale.

  For the reasoning, see Chapter 7 of the handbook (§ 3 — Working Toward the Patient’s Goals Over Time), and the functional-impact approach to intensity in Chapter 2.

  1. Recognition — Which is the patient’s goal?

  Goal

  Tell a patient’s goal apart from a clinician’s disease target.

  Task

  A patient says the knee pain stops her getting down to the floor to play with her grandchildren. In goal-oriented terms, which of these is her goal?

  • A) Reduce her pain score from 7 to 3.
  • B) Get back down to the floor to play with her grandchildren.
  • C) Improve her knee range of motion by 20 degrees.
  • D) Achieve full healing on the X-ray.

  Reveal answer

  B. The goal is the function she lost, read forwards — what she wants to do again. A, C, and D are disease or clinician targets; they may matter clinically, but they are not what she came for, and they are not how she will know she is better. In MAAS the goal is built from the functional loss you found in history-taking (“what can’t you do now that you could before?”), simply turned around. (MAAS — goal-oriented care; Ch2 functional impact)

  ---

  2. Reformulation — From functional loss to goal and tracking question

  Goal

  Turn a stated functional loss into a goal and the question that will track it.

  Task

  A patient says: “The back pain stops me lifting my toddler.” Write (a) the goal in the patient’s own terms, and (b) the question you would use at the next visit to track progress. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  (a) Goal: “to be able to lift and carry your toddler again.”
  (b) Tracking: “Since last time — can you lift him yet? How far can you carry him before it stops you?”

  Compare yours. The progress measure is the function itself, in the patient’s life — not a pain number. Notice the symmetry with history-taking: there you asked what they can’t do that they could; here you ask what they can do now that they couldn’t. Same lens, pointed forward. (MAAS A.7; Ch2 functional impact)

  ---

  3. Commit-then-compare — Eliciting the goal

  Goal

  Surface what the patient is actually trying to get back to.

  Task

  A patient with COPD is short of breath. Beyond “improve your breathing,” write one question that surfaces what they are trying to get back to. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “When your breathing is at its best, what would you be doing that you can’t do now?”
  • “What has the breathlessness stopped you doing that you most want back?”
  • “If we get this as good as it can be, what does a good day look like for you?”

  Compare yours. Each turns a vague clinical aim into a concrete, personal, trackable goal. The answer — walk to the shop, play with the dog, get upstairs to bed — becomes the thing every later visit measures against. (MAAS — goal elicitation)

  ---

  4. Spot-the-issue — Tracking the wrong currency

  Goal

  Notice when progress is reported in a currency the patient doesn’t feel.

  Task

  A patient with diabetes returns. The physician says: “Good news — your HbA1c is down to 7.2.” The patient nods, unmoved. What has the physician missed?

  Reveal answer

  The number moved, but it was never the patient’s goal, and it is not in a currency they can feel. The patient came in wanting the foot tingling that keeps them awake to settle, and to walk the dog again. Progress they can feel is progress in function: “Are you sleeping better? Managing the walk?” The lab value matters clinically — but reported alone it leaves the patient unmoved and the goal untouched. Report progress in the currency the patient lives in. (MAAS — goal tracking; Feedback Index: Goals)

  ---

  5. Apply to case — Mr. Lee’s hill

  Goal

  Track one functional goal across follow-ups.

  Task

  Mr. Lee’s goal, set at the first visit, is to walk up the hill to his allotment without the chest tightness stopping him — at first he can’t manage it without stopping twice. Write the question you would use at each follow-up to track this, and say what counts as progress. Then reveal.

  Reveal answer and feedback

  The question is the Chapter 2 question turned forward: “Since last time — how far up the hill do you get before the tightness stops you?” Progress is functional and concrete: two stops → one → none. No scale is needed; the hill is the measure, and it is the thing he came for. When he walks it without thinking, the goal is met — and you set the next one with him. (MAAS — goal tracking; Ch2 functional impact)

  Theme 2 — Follow-up consultations

  A follow-up is not the opening of a new visit. Three things need to be heard, not one: how previous concerns — including the goal you set together — are going, how the treatment has been, and whether anything new has come up. The items you practised in earlier chapters do not disappear in follow-up; they change flavour. This theme practises opening and conducting the return visit.

  For the reasoning, see Chapter 7 of the handbook (§ 4 — MAAS in Follow-Up Consultations).

  1. Recognition — One-part vs. three-part opening

  Goal

  Recognise the opening that surfaces all three agendas of a follow-up visit.

  Task

  A patient returns four weeks after starting a new medication for migraines. Which opening captures the full follow-up agenda?

  • A) “So, how’s the medication going?”
  • B) “Tell me how you’ve been. How have the headaches been, how are you finding the tablets, and is there something else you wanted to bring up today?”
  • C) “Any side effects?”
  • D) “What brings you in today?”

  Reveal answer

  B opens all three doors: the original concern (headaches), the treatment response (tablets), and new issues (something else?). A narrows to treatment. C narrows further to side effects. D treats this as a new consultation, missing the continuity — the patient may assume you know about the headaches and stay silent. The three-part opening takes about ten seconds and changes what the patient feels free to say. (MAAS 1.1, A.2 in follow-up)

  ---

  2. Reformulation — From new-visit to follow-up opening

  Goal

  Rewrite a new-consultation opening into one that fits a return visit.

  Task

  A physician greets a returning patient with: “So, what brings you in today?” The patient was seen six weeks ago for low back pain, started on physiotherapy and simple analgesia. Rewrite the opening so the patient knows you remember, and so all three agendas are open.

  Reveal exemplar and feedback

  Exemplar:

  “Good to see you again. How have things been since last time — with the back, with the physio and the painkillers, and is there something else you wanted to talk about today?”

  Compare yours with the exemplar. Two small moves do most of the work: the acknowledgement (“good to see you again”) signals continuity, and the three-part question catches what the patient may assume you already know. The patient who hears “what brings you in?” at a follow-up often hesitates to mention the back at all — and sometimes leaves without mentioning the one new symptom they came for. (MAAS 1.1 in follow-up)

  ---

  3. Spot-the-issue — Follow-up as new consultation

  Goal

  Notice when a follow-up has been opened as if it were a new visit.

  Task

  Read this exchange. What has the physician missed?

  Physician: Hi — what brings you in today?
  Patient: Um … well … you started me on that tablet for my blood pressure four weeks ago.
  Physician: Oh right, yes. And?
  Patient: It’s been OK, I suppose.
  Physician: Good. Something else?
  Patient: No, nothing.

  Reveal answer

  The physician opened as if this were a first consultation. The patient had to remind them of the reason for the visit, which shifted the emotional tone instantly — the patient is now doing the physician’s work. After that, “it’s been OK, I suppose” is a classic under-report; the patient no longer feels this consultation is about them. The closing “something else?” gets a “no” because the patient has already decided there is no space for more. A three-part opening would have surfaced both how the blood pressure has been and anything suppressed after the rocky start. (Feedback Index: Follow-Up Continuity)

  ---

  4. Reformulation — Asking about adherence without judgement

  Goal

  Rewrite a loaded adherence question into one that invites honesty.

  Task

  A physician asks: “Have you been taking the medication as I prescribed?” The question gets “yes” whether true or not. Rewrite it so the patient can tell you what has actually happened — including missed doses — without feeling caught out.

  Reveal exemplars and feedback

  Exemplars:

  • “A lot of people find it hard to take a new medication every day without missing some — how’s it been for you?”
  • “Tell me about a typical week with the tablets — when do you remember, when do you forget, any you’re deliberately skipping?”
  • “How are you finding the medication so far — both the taking of it and the effect?”

  Compare yours. The first normalises missed doses; the second asks for specifics in a way that makes them neutral information; the third separates the act of taking from the effect. None signals that the right answer is “perfectly adherent” — and patients who feel that signal default to it whether it is true or not, so the next consultation is built on bad data. (MAAS 1.7 in follow-up)

  ---

  5. Commit-then-compare — Re-checking the goal and expectations

  Goal

  Ask what the patient hopes for now, after they have had experience with treatment.

  Task

  A patient with chronic knee pain has been on treatment for three months. They are improved but not back to normal. Before deciding what to do next, you want to re-check the goal you set. Write one question that does that. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “Now you’ve had some time on this — what are you hoping for from here? Has that changed from what you wanted at the start?”
  • “Thinking about where you’ve got to — what would ‘good enough’ look like for you now?”
  • “You came in wanting to get back to gardening. With what you know now, is that still the goal, or has it shifted?”

  Compare yours. All three acknowledge that the patient now has something they didn’t at the first visit: lived experience with the treatment. Goals drift — becoming more realistic, sometimes more pessimistic. A patient whose goal has shifted, and hasn’t had that reflected back, often feels the plan is for a version of themselves they no longer are. (MAAS 3.4 in follow-up)

  Theme 3 — Continuity and handoffs

  Patients move between clinicians; continuity is how care — and the goal — survives those transitions. It has three dimensions, each failing differently and repaired differently: informational, management, and relational. This theme practises recognising them, taking over a patient without starting from zero, and writing a handoff that carries more than a problem list.

  For the reasoning, see Chapter 7 of the handbook (§ 5 — Continuity and Handoffs).

  1. Recognition — Three kinds of continuity

  Goal

  Recognise the three forms continuity takes — informational, management, and relational.

  Task

  A patient is transferring from one GP practice to another, mid-treatment for a complex condition. Which form of continuity is most under threat?

  • A) Relational — the ongoing doctor-patient relationship
  • B) Informational — records transferring accurately
  • C) Management — the care plan holding together across clinicians
  • D) All three are under threat in different ways.

  Reveal answer

  D. A practice transfer threatens all three — but each in a different way and with a different fix. Relational is gone (the new doctor has no history); the answer is to rebuild, not to claim it. Informational is at risk if records don’t transfer fully or in time; the fix is structured handover notes and asking the patient what they remember. Management is at risk when the old plan doesn’t make sense to the new doctor; the fix is an explicit review of what was being worked toward, not just what was done. The three kinds fail differently and are repaired differently. (MAAS — continuity)

  ---

  2. Apply to case — Taking over a patient mid-journey

  Goal

  Find the moves that let you take over a patient’s care without starting from zero.

  Task

  You are seeing a patient for the first time. Your colleague, on extended leave, has been seeing them for eight months for recurrent anxiety. The records are brief. Write down three questions you would ask in your opening ten minutes. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “I’ve read your notes, but I’d like to hear it from you: what have you been coming to see Dr. X about, and how have things been?”
  • “What has been working for you so far? And what’s been harder?”
  • “Is there something you’ve been meaning to raise but didn’t get round to, that you’d like to talk about today?”

  Compare yours. The three do different jobs: the first respects the patient as the constant thread through their own care (they often know things the chart does not); the second pulls out what has worked and what hasn’t — critical for continuing treatment; the third opens the door for something held back for the new clinician. Done this way, a handover takes ten minutes and lands the patient on steady ground. Done as “so … what brings you in?” it restarts from zero. (MAAS — handover)

  ---

  3. Spot-the-issue — The handoff that carries only the problem list

  Goal

  Notice what a problem-and-medication handoff leaves out.

  Task

  A handoff note reads, in full:

  “58M. Stable angina. On aspirin, atorvastatin, bisoprolol, GTN spray PRN. BP and lipids at target. Annual review due.”

  It is accurate. What does the next clinician still not know?

  Reveal answer

  Everything that makes the care this patient’s: what he is working toward (walking up the hill to his allotment), what he fears (his father’s heart disease), and what nearly derailed treatment (statin worry from reading online). The note carries the disease and the drugs; it drops the goal, the fear, and the history of the relationship — exactly the things that let the next clinician continue rather than restart. A good handoff carries the goal, not just the problem list. (MAAS — continuity; Feedback Index: Handover)

  ---

  4. Reformulation — Writing a handoff that travels

  Goal

  Add the lines that make a handoff usable by the next reader.

  Task

  Take the problem-list note above and add two or three short lines so the next clinician can continue Mr. Lee’s care, not restart it. Then reveal.

  Reveal exemplar and feedback

  Exemplar additions:

  “Goal: back to walking up to his allotment without chest tightness — nearly there. Fears recurrence (father’s MI at 62). Statin adherence wobbled early after reading about side effects online; settled once discussed openly — worth checking gently. Values frankness; dislikes feeling ‘dependent’ on tablets.”

  Compare yours. The clinical facts were already there; what you added is what the facts are for — the goal that measures progress, the fear that shapes how news lands, the adherence story, what he values. A handoff that carries these lets the next consultation open with continuity rather than a cold start. (MAAS — handover)

  Theme 4 — Longitudinal practice

  Following patients over time teaches things a single consultation cannot. You can’t drill longitudinal experience — only learn to notice it. This theme reads one patient, Mr. Lee, across a year, and reflects on what the arc teaches you.

  For the reasoning, see Chapter 7 of the handbook (§ 6 — Mr. Lee Over Time · § 7 — Your Development Through Longitudinal Care).

  1. Recognition — What only the arc teaches

  Goal

  Recognise what you can mostly learn only by seeing a patient more than once.

  Task

  Which of these is learnable mostly only by following a patient across several visits?

  • A) How to take a structured history.
  • B) Whether the treatment you chose actually worked, and the advice the patient tried and then abandoned.
  • C) The anatomy relevant to the complaint.
  • D) How to examine a joint.

  Reveal answer

  B. A, C, and D are learnable from books, a single encounter, or simulation. B — real outcomes, adherence as it actually plays out, the diagnosis that only declares itself over time — is visible only in the arc. This is why curiosity at follow-up (“what happened since?”) accelerates your learning: the arc is the teacher, and your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  ---

  2. Apply to case — Mr. Lee across four visits

  Goal

  Read a patient’s arc across a year and notice what changes in the consultation as the relationship develops.

  Task

  Mr. Lee is fifty-eight. His arc:

  • First visit: Comes in for a blood-pressure check. Exploration uncovers chest pain he hadn’t mentioned, fear about his father’s heart disease, worry about his own. Diagnosed with angina. Treatment started. Goal named in his terms: to get back up the hill to his allotment without the tightness stopping him.
  • Four-week follow-up: Chest pain better — he made the hill last week with one pause instead of two. But he is tired, and admits he hasn’t been taking the statin every day, after reading about side effects online.
  • Six months later: He comes back with occasional palpitations. He trusts you enough now to mention it early, not wait until it is severe. He’s walking the hill without stopping.
  • Annual review: A year on. The acute problem has become a well-managed chronic condition. The consultation is briefer. You ask about his granddaughter starting school, about his wife’s health scare. Walking has become part of who he is — the original goal is met, and you set the next one with him.

  Note two or three things that have changed in the consultation itself across these four visits. Then reveal.

  Reveal answer and feedback

  Changes worth noticing:

  • The exploration shortens but deepens. At visit one, the full Reasons for Encounter was needed to surface hidden chest pain and fear. By the annual review the relationship carries that context — you can go straight to what matters.
  • Trust moves earlier in the arc. At six months Mr. Lee raises the palpitations early, not at the doorknob. That is a signal about the relationship, not the symptom.
  • Beliefs and the goal keep updating. The statin concern (visit two) isn’t a failure of the original explanation; it is Mr. Lee having taken it home and kept thinking. Follow-up revisits it — and the goal is what each visit measures against.
  • The proportions shift. Visit one was heavy on diagnosis and relationship-building; the annual review is mostly relationship and planning with a quick diagnostic check. Neither is the right mix — each is right for that point in the arc.

  Compare your list. You may have noticed different things — all are evidence of what longitudinal care does. The single most important change is the smallest: by the annual review, Mr. Lee is a person you know, not a case you are managing. That is what good clinical care, over years, builds. (MAAS — the patient journey)

  ---

  3. Reflection — What the arc teaches you

  Goal

  Name what changes for you — not for the patient — across a long arc of care.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Name one thing you think you can only learn by seeing a patient more than once.
  2. What would you want to know about a patient you are taking over from a colleague — beyond what the record holds?
  3. Think of a patient goal you have seen, or can imagine. What would tell you, over time, that you were moving toward it?
  4. What is one small thing you want to carry into your next follow-up (real or simulated) — one move you’ll try, one thing you’ll look for?

  Reveal reflection

  This exercise has no answer key. What matters is that you can name, honestly, what longitudinal care will teach you that a single visit cannot.

  Some things are only visible in the arc: whether the treatment you chose actually works; the diagnosis you missed that now reveals itself; the advice the patient tried and abandoned; the goal that was reached, or quietly revised, over months. You will not see those in the first two years of training, and you will see them for the rest of your career.

  Students who bring curiosity to follow-ups — asking “what happened since?” rather than “what brings you in today?” — speed up the feedback loop. The arc is the teacher; your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  That completes Chapter 7. You have now worked through a single consultation and the arc a patient travels across many of them — the goal that gives the arc its direction, the follow-ups that advance it, the continuity that carries it, and what the whole journey teaches you. The final chapters turn to context — how the patient’s world outside the room shapes what happens inside it — and to how the skills you have built sit inside a professional life.

• 7.2Theme 2 — Follow-up consultations

  A follow-up is not the opening of a new visit. Three things need to be heard, not one: how previous concerns — including the goal you set together — are going, how the treatment has been, and whether anything new has come up. The items you practised in earlier chapters do not disappear in follow-up; they change flavour. This theme practises opening and conducting the return visit.

  For the reasoning, see Chapter 7 of the handbook (§ 4 — MAAS in Follow-Up Consultations).

  1. Recognition — One-part vs. three-part opening

  Goal

  Recognise the opening that surfaces all three agendas of a follow-up visit.

  Task

  A patient returns four weeks after starting a new medication for migraines. Which opening captures the full follow-up agenda?

  • A) “So, how’s the medication going?”
  • B) “Tell me how you’ve been. How have the headaches been, how are you finding the tablets, and is there something else you wanted to bring up today?”
  • C) “Any side effects?”
  • D) “What brings you in today?”

  Reveal answer

  B opens all three doors: the original concern (headaches), the treatment response (tablets), and new issues (something else?). A narrows to treatment. C narrows further to side effects. D treats this as a new consultation, missing the continuity — the patient may assume you know about the headaches and stay silent. The three-part opening takes about ten seconds and changes what the patient feels free to say. (MAAS 1.1, A.2 in follow-up)

  ---

  2. Reformulation — From new-visit to follow-up opening

  Goal

  Rewrite a new-consultation opening into one that fits a return visit.

  Task

  A physician greets a returning patient with: “So, what brings you in today?” The patient was seen six weeks ago for low back pain, started on physiotherapy and simple analgesia. Rewrite the opening so the patient knows you remember, and so all three agendas are open.

  Reveal exemplar and feedback

  Exemplar:

  “Good to see you again. How have things been since last time — with the back, with the physio and the painkillers, and is there something else you wanted to talk about today?”

  Compare yours with the exemplar. Two small moves do most of the work: the acknowledgement (“good to see you again”) signals continuity, and the three-part question catches what the patient may assume you already know. The patient who hears “what brings you in?” at a follow-up often hesitates to mention the back at all — and sometimes leaves without mentioning the one new symptom they came for. (MAAS 1.1 in follow-up)

  ---

  3. Spot-the-issue — Follow-up as new consultation

  Goal

  Notice when a follow-up has been opened as if it were a new visit.

  Task

  Read this exchange. What has the physician missed?

  Physician: Hi — what brings you in today?
  Patient: Um … well … you started me on that tablet for my blood pressure four weeks ago.
  Physician: Oh right, yes. And?
  Patient: It’s been OK, I suppose.
  Physician: Good. Something else?
  Patient: No, nothing.

  Reveal answer

  The physician opened as if this were a first consultation. The patient had to remind them of the reason for the visit, which shifted the emotional tone instantly — the patient is now doing the physician’s work. After that, “it’s been OK, I suppose” is a classic under-report; the patient no longer feels this consultation is about them. The closing “something else?” gets a “no” because the patient has already decided there is no space for more. A three-part opening would have surfaced both how the blood pressure has been and anything suppressed after the rocky start. (Feedback Index: Follow-Up Continuity)

  ---

  4. Reformulation — Asking about adherence without judgement

  Goal

  Rewrite a loaded adherence question into one that invites honesty.

  Task

  A physician asks: “Have you been taking the medication as I prescribed?” The question gets “yes” whether true or not. Rewrite it so the patient can tell you what has actually happened — including missed doses — without feeling caught out.

  Reveal exemplars and feedback

  Exemplars:

  • “A lot of people find it hard to take a new medication every day without missing some — how’s it been for you?”
  • “Tell me about a typical week with the tablets — when do you remember, when do you forget, any you’re deliberately skipping?”
  • “How are you finding the medication so far — both the taking of it and the effect?”

  Compare yours. The first normalises missed doses; the second asks for specifics in a way that makes them neutral information; the third separates the act of taking from the effect. None signals that the right answer is “perfectly adherent” — and patients who feel that signal default to it whether it is true or not, so the next consultation is built on bad data. (MAAS 1.7 in follow-up)

  ---

  5. Commit-then-compare — Re-checking the goal and expectations

  Goal

  Ask what the patient hopes for now, after they have had experience with treatment.

  Task

  A patient with chronic knee pain has been on treatment for three months. They are improved but not back to normal. Before deciding what to do next, you want to re-check the goal you set. Write one question that does that. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “Now you’ve had some time on this — what are you hoping for from here? Has that changed from what you wanted at the start?”
  • “Thinking about where you’ve got to — what would ‘good enough’ look like for you now?”
  • “You came in wanting to get back to gardening. With what you know now, is that still the goal, or has it shifted?”

  Compare yours. All three acknowledge that the patient now has something they didn’t at the first visit: lived experience with the treatment. Goals drift — becoming more realistic, sometimes more pessimistic. A patient whose goal has shifted, and hasn’t had that reflected back, often feels the plan is for a version of themselves they no longer are. (MAAS 3.4 in follow-up)

  Theme 3 — Continuity and handoffs

  Patients move between clinicians; continuity is how care — and the goal — survives those transitions. It has three dimensions, each failing differently and repaired differently: informational, management, and relational. This theme practises recognising them, taking over a patient without starting from zero, and writing a handoff that carries more than a problem list.

  For the reasoning, see Chapter 7 of the handbook (§ 5 — Continuity and Handoffs).

  1. Recognition — Three kinds of continuity

  Goal

  Recognise the three forms continuity takes — informational, management, and relational.

  Task

  A patient is transferring from one GP practice to another, mid-treatment for a complex condition. Which form of continuity is most under threat?

  • A) Relational — the ongoing doctor-patient relationship
  • B) Informational — records transferring accurately
  • C) Management — the care plan holding together across clinicians
  • D) All three are under threat in different ways.

  Reveal answer

  D. A practice transfer threatens all three — but each in a different way and with a different fix. Relational is gone (the new doctor has no history); the answer is to rebuild, not to claim it. Informational is at risk if records don’t transfer fully or in time; the fix is structured handover notes and asking the patient what they remember. Management is at risk when the old plan doesn’t make sense to the new doctor; the fix is an explicit review of what was being worked toward, not just what was done. The three kinds fail differently and are repaired differently. (MAAS — continuity)

  ---

  2. Apply to case — Taking over a patient mid-journey

  Goal

  Find the moves that let you take over a patient’s care without starting from zero.

  Task

  You are seeing a patient for the first time. Your colleague, on extended leave, has been seeing them for eight months for recurrent anxiety. The records are brief. Write down three questions you would ask in your opening ten minutes. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “I’ve read your notes, but I’d like to hear it from you: what have you been coming to see Dr. X about, and how have things been?”
  • “What has been working for you so far? And what’s been harder?”
  • “Is there something you’ve been meaning to raise but didn’t get round to, that you’d like to talk about today?”

  Compare yours. The three do different jobs: the first respects the patient as the constant thread through their own care (they often know things the chart does not); the second pulls out what has worked and what hasn’t — critical for continuing treatment; the third opens the door for something held back for the new clinician. Done this way, a handover takes ten minutes and lands the patient on steady ground. Done as “so … what brings you in?” it restarts from zero. (MAAS — handover)

  ---

  3. Spot-the-issue — The handoff that carries only the problem list

  Goal

  Notice what a problem-and-medication handoff leaves out.

  Task

  A handoff note reads, in full:

  “58M. Stable angina. On aspirin, atorvastatin, bisoprolol, GTN spray PRN. BP and lipids at target. Annual review due.”

  It is accurate. What does the next clinician still not know?

  Reveal answer

  Everything that makes the care this patient’s: what he is working toward (walking up the hill to his allotment), what he fears (his father’s heart disease), and what nearly derailed treatment (statin worry from reading online). The note carries the disease and the drugs; it drops the goal, the fear, and the history of the relationship — exactly the things that let the next clinician continue rather than restart. A good handoff carries the goal, not just the problem list. (MAAS — continuity; Feedback Index: Handover)

  ---

  4. Reformulation — Writing a handoff that travels

  Goal

  Add the lines that make a handoff usable by the next reader.

  Task

  Take the problem-list note above and add two or three short lines so the next clinician can continue Mr. Lee’s care, not restart it. Then reveal.

  Reveal exemplar and feedback

  Exemplar additions:

  “Goal: back to walking up to his allotment without chest tightness — nearly there. Fears recurrence (father’s MI at 62). Statin adherence wobbled early after reading about side effects online; settled once discussed openly — worth checking gently. Values frankness; dislikes feeling ‘dependent’ on tablets.”

  Compare yours. The clinical facts were already there; what you added is what the facts are for — the goal that measures progress, the fear that shapes how news lands, the adherence story, what he values. A handoff that carries these lets the next consultation open with continuity rather than a cold start. (MAAS — handover)

  Theme 4 — Longitudinal practice

  Following patients over time teaches things a single consultation cannot. You can’t drill longitudinal experience — only learn to notice it. This theme reads one patient, Mr. Lee, across a year, and reflects on what the arc teaches you.

  For the reasoning, see Chapter 7 of the handbook (§ 6 — Mr. Lee Over Time · § 7 — Your Development Through Longitudinal Care).

  1. Recognition — What only the arc teaches

  Goal

  Recognise what you can mostly learn only by seeing a patient more than once.

  Task

  Which of these is learnable mostly only by following a patient across several visits?

  • A) How to take a structured history.
  • B) Whether the treatment you chose actually worked, and the advice the patient tried and then abandoned.
  • C) The anatomy relevant to the complaint.
  • D) How to examine a joint.

  Reveal answer

  B. A, C, and D are learnable from books, a single encounter, or simulation. B — real outcomes, adherence as it actually plays out, the diagnosis that only declares itself over time — is visible only in the arc. This is why curiosity at follow-up (“what happened since?”) accelerates your learning: the arc is the teacher, and your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  ---

  2. Apply to case — Mr. Lee across four visits

  Goal

  Read a patient’s arc across a year and notice what changes in the consultation as the relationship develops.

  Task

  Mr. Lee is fifty-eight. His arc:

  • First visit: Comes in for a blood-pressure check. Exploration uncovers chest pain he hadn’t mentioned, fear about his father’s heart disease, worry about his own. Diagnosed with angina. Treatment started. Goal named in his terms: to get back up the hill to his allotment without the tightness stopping him.
  • Four-week follow-up: Chest pain better — he made the hill last week with one pause instead of two. But he is tired, and admits he hasn’t been taking the statin every day, after reading about side effects online.
  • Six months later: He comes back with occasional palpitations. He trusts you enough now to mention it early, not wait until it is severe. He’s walking the hill without stopping.
  • Annual review: A year on. The acute problem has become a well-managed chronic condition. The consultation is briefer. You ask about his granddaughter starting school, about his wife’s health scare. Walking has become part of who he is — the original goal is met, and you set the next one with him.

  Note two or three things that have changed in the consultation itself across these four visits. Then reveal.

  Reveal answer and feedback

  Changes worth noticing:

  • The exploration shortens but deepens. At visit one, the full Reasons for Encounter was needed to surface hidden chest pain and fear. By the annual review the relationship carries that context — you can go straight to what matters.
  • Trust moves earlier in the arc. At six months Mr. Lee raises the palpitations early, not at the doorknob. That is a signal about the relationship, not the symptom.
  • Beliefs and the goal keep updating. The statin concern (visit two) isn’t a failure of the original explanation; it is Mr. Lee having taken it home and kept thinking. Follow-up revisits it — and the goal is what each visit measures against.
  • The proportions shift. Visit one was heavy on diagnosis and relationship-building; the annual review is mostly relationship and planning with a quick diagnostic check. Neither is the right mix — each is right for that point in the arc.

  Compare your list. You may have noticed different things — all are evidence of what longitudinal care does. The single most important change is the smallest: by the annual review, Mr. Lee is a person you know, not a case you are managing. That is what good clinical care, over years, builds. (MAAS — the patient journey)

  ---

  3. Reflection — What the arc teaches you

  Goal

  Name what changes for you — not for the patient — across a long arc of care.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Name one thing you think you can only learn by seeing a patient more than once.
  2. What would you want to know about a patient you are taking over from a colleague — beyond what the record holds?
  3. Think of a patient goal you have seen, or can imagine. What would tell you, over time, that you were moving toward it?
  4. What is one small thing you want to carry into your next follow-up (real or simulated) — one move you’ll try, one thing you’ll look for?

  Reveal reflection

  This exercise has no answer key. What matters is that you can name, honestly, what longitudinal care will teach you that a single visit cannot.

  Some things are only visible in the arc: whether the treatment you chose actually works; the diagnosis you missed that now reveals itself; the advice the patient tried and abandoned; the goal that was reached, or quietly revised, over months. You will not see those in the first two years of training, and you will see them for the rest of your career.

  Students who bring curiosity to follow-ups — asking “what happened since?” rather than “what brings you in today?” — speed up the feedback loop. The arc is the teacher; your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  That completes Chapter 7. You have now worked through a single consultation and the arc a patient travels across many of them — the goal that gives the arc its direction, the follow-ups that advance it, the continuity that carries it, and what the whole journey teaches you. The final chapters turn to context — how the patient’s world outside the room shapes what happens inside it — and to how the skills you have built sit inside a professional life.

• 7.3Theme 3 — Continuity and handoffs

  Patients move between clinicians; continuity is how care — and the goal — survives those transitions. It has three dimensions, each failing differently and repaired differently: informational, management, and relational. This theme practises recognising them, taking over a patient without starting from zero, and writing a handoff that carries more than a problem list.

  For the reasoning, see Chapter 7 of the handbook (§ 5 — Continuity and Handoffs).

  1. Recognition — Three kinds of continuity

  Goal

  Recognise the three forms continuity takes — informational, management, and relational.

  Task

  A patient is transferring from one GP practice to another, mid-treatment for a complex condition. Which form of continuity is most under threat?

  • A) Relational — the ongoing doctor-patient relationship
  • B) Informational — records transferring accurately
  • C) Management — the care plan holding together across clinicians
  • D) All three are under threat in different ways.

  Reveal answer

  D. A practice transfer threatens all three — but each in a different way and with a different fix. Relational is gone (the new doctor has no history); the answer is to rebuild, not to claim it. Informational is at risk if records don’t transfer fully or in time; the fix is structured handover notes and asking the patient what they remember. Management is at risk when the old plan doesn’t make sense to the new doctor; the fix is an explicit review of what was being worked toward, not just what was done. The three kinds fail differently and are repaired differently. (MAAS — continuity)

  ---

  2. Apply to case — Taking over a patient mid-journey

  Goal

  Find the moves that let you take over a patient’s care without starting from zero.

  Task

  You are seeing a patient for the first time. Your colleague, on extended leave, has been seeing them for eight months for recurrent anxiety. The records are brief. Write down three questions you would ask in your opening ten minutes. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “I’ve read your notes, but I’d like to hear it from you: what have you been coming to see Dr. X about, and how have things been?”
  • “What has been working for you so far? And what’s been harder?”
  • “Is there something you’ve been meaning to raise but didn’t get round to, that you’d like to talk about today?”

  Compare yours. The three do different jobs: the first respects the patient as the constant thread through their own care (they often know things the chart does not); the second pulls out what has worked and what hasn’t — critical for continuing treatment; the third opens the door for something held back for the new clinician. Done this way, a handover takes ten minutes and lands the patient on steady ground. Done as “so … what brings you in?” it restarts from zero. (MAAS — handover)

  ---

  3. Spot-the-issue — The handoff that carries only the problem list

  Goal

  Notice what a problem-and-medication handoff leaves out.

  Task

  A handoff note reads, in full:

  “58M. Stable angina. On aspirin, atorvastatin, bisoprolol, GTN spray PRN. BP and lipids at target. Annual review due.”

  It is accurate. What does the next clinician still not know?

  Reveal answer

  Everything that makes the care this patient’s: what he is working toward (walking up the hill to his allotment), what he fears (his father’s heart disease), and what nearly derailed treatment (statin worry from reading online). The note carries the disease and the drugs; it drops the goal, the fear, and the history of the relationship — exactly the things that let the next clinician continue rather than restart. A good handoff carries the goal, not just the problem list. (MAAS — continuity; Feedback Index: Handover)

  ---

  4. Reformulation — Writing a handoff that travels

  Goal

  Add the lines that make a handoff usable by the next reader.

  Task

  Take the problem-list note above and add two or three short lines so the next clinician can continue Mr. Lee’s care, not restart it. Then reveal.

  Reveal exemplar and feedback

  Exemplar additions:

  “Goal: back to walking up to his allotment without chest tightness — nearly there. Fears recurrence (father’s MI at 62). Statin adherence wobbled early after reading about side effects online; settled once discussed openly — worth checking gently. Values frankness; dislikes feeling ‘dependent’ on tablets.”

  Compare yours. The clinical facts were already there; what you added is what the facts are for — the goal that measures progress, the fear that shapes how news lands, the adherence story, what he values. A handoff that carries these lets the next consultation open with continuity rather than a cold start. (MAAS — handover)

  Theme 4 — Longitudinal practice

  Following patients over time teaches things a single consultation cannot. You can’t drill longitudinal experience — only learn to notice it. This theme reads one patient, Mr. Lee, across a year, and reflects on what the arc teaches you.

  For the reasoning, see Chapter 7 of the handbook (§ 6 — Mr. Lee Over Time · § 7 — Your Development Through Longitudinal Care).

  1. Recognition — What only the arc teaches

  Goal

  Recognise what you can mostly learn only by seeing a patient more than once.

  Task

  Which of these is learnable mostly only by following a patient across several visits?

  • A) How to take a structured history.
  • B) Whether the treatment you chose actually worked, and the advice the patient tried and then abandoned.
  • C) The anatomy relevant to the complaint.
  • D) How to examine a joint.

  Reveal answer

  B. A, C, and D are learnable from books, a single encounter, or simulation. B — real outcomes, adherence as it actually plays out, the diagnosis that only declares itself over time — is visible only in the arc. This is why curiosity at follow-up (“what happened since?”) accelerates your learning: the arc is the teacher, and your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  ---

  2. Apply to case — Mr. Lee across four visits

  Goal

  Read a patient’s arc across a year and notice what changes in the consultation as the relationship develops.

  Task

  Mr. Lee is fifty-eight. His arc:

  • First visit: Comes in for a blood-pressure check. Exploration uncovers chest pain he hadn’t mentioned, fear about his father’s heart disease, worry about his own. Diagnosed with angina. Treatment started. Goal named in his terms: to get back up the hill to his allotment without the tightness stopping him.
  • Four-week follow-up: Chest pain better — he made the hill last week with one pause instead of two. But he is tired, and admits he hasn’t been taking the statin every day, after reading about side effects online.
  • Six months later: He comes back with occasional palpitations. He trusts you enough now to mention it early, not wait until it is severe. He’s walking the hill without stopping.
  • Annual review: A year on. The acute problem has become a well-managed chronic condition. The consultation is briefer. You ask about his granddaughter starting school, about his wife’s health scare. Walking has become part of who he is — the original goal is met, and you set the next one with him.

  Note two or three things that have changed in the consultation itself across these four visits. Then reveal.

  Reveal answer and feedback

  Changes worth noticing:

  • The exploration shortens but deepens. At visit one, the full Reasons for Encounter was needed to surface hidden chest pain and fear. By the annual review the relationship carries that context — you can go straight to what matters.
  • Trust moves earlier in the arc. At six months Mr. Lee raises the palpitations early, not at the doorknob. That is a signal about the relationship, not the symptom.
  • Beliefs and the goal keep updating. The statin concern (visit two) isn’t a failure of the original explanation; it is Mr. Lee having taken it home and kept thinking. Follow-up revisits it — and the goal is what each visit measures against.
  • The proportions shift. Visit one was heavy on diagnosis and relationship-building; the annual review is mostly relationship and planning with a quick diagnostic check. Neither is the right mix — each is right for that point in the arc.

  Compare your list. You may have noticed different things — all are evidence of what longitudinal care does. The single most important change is the smallest: by the annual review, Mr. Lee is a person you know, not a case you are managing. That is what good clinical care, over years, builds. (MAAS — the patient journey)

  ---

  3. Reflection — What the arc teaches you

  Goal

  Name what changes for you — not for the patient — across a long arc of care.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Name one thing you think you can only learn by seeing a patient more than once.
  2. What would you want to know about a patient you are taking over from a colleague — beyond what the record holds?
  3. Think of a patient goal you have seen, or can imagine. What would tell you, over time, that you were moving toward it?
  4. What is one small thing you want to carry into your next follow-up (real or simulated) — one move you’ll try, one thing you’ll look for?

  Reveal reflection

  This exercise has no answer key. What matters is that you can name, honestly, what longitudinal care will teach you that a single visit cannot.

  Some things are only visible in the arc: whether the treatment you chose actually works; the diagnosis you missed that now reveals itself; the advice the patient tried and abandoned; the goal that was reached, or quietly revised, over months. You will not see those in the first two years of training, and you will see them for the rest of your career.

  Students who bring curiosity to follow-ups — asking “what happened since?” rather than “what brings you in today?” — speed up the feedback loop. The arc is the teacher; your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  That completes Chapter 7. You have now worked through a single consultation and the arc a patient travels across many of them — the goal that gives the arc its direction, the follow-ups that advance it, the continuity that carries it, and what the whole journey teaches you. The final chapters turn to context — how the patient’s world outside the room shapes what happens inside it — and to how the skills you have built sit inside a professional life.

• 7.4Theme 4 — Longitudinal practice

  Following patients over time teaches things a single consultation cannot. You can’t drill longitudinal experience — only learn to notice it. This theme reads one patient, Mr. Lee, across a year, and reflects on what the arc teaches you.

  For the reasoning, see Chapter 7 of the handbook (§ 6 — Mr. Lee Over Time · § 7 — Your Development Through Longitudinal Care).

  1. Recognition — What only the arc teaches

  Goal

  Recognise what you can mostly learn only by seeing a patient more than once.

  Task

  Which of these is learnable mostly only by following a patient across several visits?

  • A) How to take a structured history.
  • B) Whether the treatment you chose actually worked, and the advice the patient tried and then abandoned.
  • C) The anatomy relevant to the complaint.
  • D) How to examine a joint.

  Reveal answer

  B. A, C, and D are learnable from books, a single encounter, or simulation. B — real outcomes, adherence as it actually plays out, the diagnosis that only declares itself over time — is visible only in the arc. This is why curiosity at follow-up (“what happened since?”) accelerates your learning: the arc is the teacher, and your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  ---

  2. Apply to case — Mr. Lee across four visits

  Goal

  Read a patient’s arc across a year and notice what changes in the consultation as the relationship develops.

  Task

  Mr. Lee is fifty-eight. His arc:

  • First visit: Comes in for a blood-pressure check. Exploration uncovers chest pain he hadn’t mentioned, fear about his father’s heart disease, worry about his own. Diagnosed with angina. Treatment started. Goal named in his terms: to get back up the hill to his allotment without the tightness stopping him.
  • Four-week follow-up: Chest pain better — he made the hill last week with one pause instead of two. But he is tired, and admits he hasn’t been taking the statin every day, after reading about side effects online.
  • Six months later: He comes back with occasional palpitations. He trusts you enough now to mention it early, not wait until it is severe. He’s walking the hill without stopping.
  • Annual review: A year on. The acute problem has become a well-managed chronic condition. The consultation is briefer. You ask about his granddaughter starting school, about his wife’s health scare. Walking has become part of who he is — the original goal is met, and you set the next one with him.

  Note two or three things that have changed in the consultation itself across these four visits. Then reveal.

  Reveal answer and feedback

  Changes worth noticing:

  • The exploration shortens but deepens. At visit one, the full Reasons for Encounter was needed to surface hidden chest pain and fear. By the annual review the relationship carries that context — you can go straight to what matters.
  • Trust moves earlier in the arc. At six months Mr. Lee raises the palpitations early, not at the doorknob. That is a signal about the relationship, not the symptom.
  • Beliefs and the goal keep updating. The statin concern (visit two) isn’t a failure of the original explanation; it is Mr. Lee having taken it home and kept thinking. Follow-up revisits it — and the goal is what each visit measures against.
  • The proportions shift. Visit one was heavy on diagnosis and relationship-building; the annual review is mostly relationship and planning with a quick diagnostic check. Neither is the right mix — each is right for that point in the arc.

  Compare your list. You may have noticed different things — all are evidence of what longitudinal care does. The single most important change is the smallest: by the annual review, Mr. Lee is a person you know, not a case you are managing. That is what good clinical care, over years, builds. (MAAS — the patient journey)

  ---

  3. Reflection — What the arc teaches you

  Goal

  Name what changes for you — not for the patient — across a long arc of care.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Name one thing you think you can only learn by seeing a patient more than once.
  2. What would you want to know about a patient you are taking over from a colleague — beyond what the record holds?
  3. Think of a patient goal you have seen, or can imagine. What would tell you, over time, that you were moving toward it?
  4. What is one small thing you want to carry into your next follow-up (real or simulated) — one move you’ll try, one thing you’ll look for?

  Reveal reflection

  This exercise has no answer key. What matters is that you can name, honestly, what longitudinal care will teach you that a single visit cannot.

  Some things are only visible in the arc: whether the treatment you chose actually works; the diagnosis you missed that now reveals itself; the advice the patient tried and abandoned; the goal that was reached, or quietly revised, over months. You will not see those in the first two years of training, and you will see them for the rest of your career.

  Students who bring curiosity to follow-ups — asking “what happened since?” rather than “what brings you in today?” — speed up the feedback loop. The arc is the teacher; your attention to it is what lets the teaching land. (MAAS — longitudinal development)

  That completes Chapter 7. You have now worked through a single consultation and the arc a patient travels across many of them — the goal that gives the arc its direction, the follow-ups that advance it, the continuity that carries it, and what the whole journey teaches you. The final chapters turn to context — how the patient’s world outside the room shapes what happens inside it — and to how the skills you have built sit inside a professional life.

8Chapter 8. Contextual Factors

• 8.1Theme 1 — Health literacy and plain language

  Between four and eight of every ten patients struggle with standard medical information — and there is no reliable way to tell by looking. University degrees, professional dress, and confident speech do not predict health literacy. The response is not to sort patients into categories, but to design every explanation for the most vulnerable reader. That is universal design, and it improves outcomes for everyone.

  For the reasoning, see Chapter 8 of the handbook (§ 2 — Health Literacy), and MAAS items C.7, 3.12.

  1. Recognition — Who has low health literacy?

  Goal

  Recognise that health literacy cannot be read from external cues.

  Task

  Which of these patients is most likely to struggle with medical information you give them today?

  • A) A 68-year-old woman who left school at fifteen, arrived to the consultation quiet, and said little.
  • B) A 42-year-old lawyer in a suit, confident and articulate, with a folder of notes.
  • C) A 25-year-old university student who speaks English as a second language.
  • D) Any of them — you cannot tell by looking.

  Reveal answer

  D. Health literacy is not predicted by education, profession, fluency, or confidence. A lawyer can misunderstand a prognosis just as easily as a pensioner — medical content is a separate domain, and it is unfamiliar to most people regardless of their overall literacy. The research consistently shows that physicians are poor judges of who will struggle and who will not. The response is universal design: use plain language with everyone, use teach-back with everyone. You cannot sort, but you can scaffold every consultation the same way. (MAAS — universal design)

  ---

  2. Reformulation — Jargon to plain, in context

  Goal

  Rewrite a clinical explanation so any patient can hold the information.

  Task

  A physician says: “Your renal function has declined slightly, likely secondary to your antihypertensive medication — we’ll monitor your eGFR and adjust accordingly.” Rewrite this so any patient can understand it without needing to ask for translation.

  Reveal exemplar and feedback

  Exemplar:

  “Your kidneys are working a little less well than they were — probably because of one of your blood-pressure tablets. We’ll do another blood test in a few weeks to see what the kidneys are doing, and if needed we’ll adjust the tablet.”

  Compare yours with the exemplar. Notice the moves: renal function became kidneys, antihypertensive became blood-pressure tablet, eGFR became another blood test, secondary to became because of. Each substitution replaced a term with a description the patient could hold in mind. Plain language is not dumbing down — it is refusing to hide behind precision. A patient who understands what you said adheres, returns, and tells you when something changes. (MAAS C.7)

  ---

  3. Recognition — Teach-back for every patient

  Goal

  Recognise the universal-design principle that teach-back is not reserved for patients you think need it.

  Task

  Which statement best reflects good practice?

  • A) Use teach-back when you suspect the patient hasn’t followed your explanation.
  • B) Use teach-back with patients who speak English as a second language.
  • C) Use teach-back with every patient after any substantial explanation.
  • D) Use teach-back only with patients who ask a lot of questions.

  Reveal answer

  C. The evidence that teach-back reduces readmissions by 45% comes from using it with every patient, not just a selected few. Using teach-back selectively — “only when I sense confusion” — misses precisely the patients who are confused and do not show it, which is most of them. Universal use also removes the awkwardness: when it is your routine, no one feels singled out. A, B, and D are all selective criteria based on physician judgement, which is the poor predictor the chapter warns against. (MAAS 3.12)

  ---

  4. Spot-the-issue — The confident patient

  Goal

  Notice when a physician has decided a patient does not need scaffolding, based on external cues.

  Task

  Read this exchange. What assumption has the physician made?

  Physician: So the plan is anticoagulation — we’ll start you on apixaban, five milligrams twice daily, and we’ll do an INR in six weeks. You’re a retired pharmacist — you’ll know the drill. Any questions?
  Patient: No, no, I’m fine with all that. Thanks.
  Physician: Great — see you in six weeks.

  Reveal answer

  The physician assumed that the patient’s professional background removed the need for the usual scaffolding — no teach-back, no check of whether “the drill” here matches the drill of a pharmacy career ten years ago. The patient’s “I’m fine with all that” may be true or may be the socially required response to being told you already know. Three additional details matter for this patient — apixaban does not need INR monitoring, so the follow-up plan is wrong; the dose is correct for most patients but not all; and the patient may or may not realise either of these. Expert knowledge from another era does not remove the need for teach-back. (Feedback Index: Health Literacy)

  Theme 2 — Cultural humility

  Cultural competence sounds like expertise — a body of knowledge about this group and that practice. Cultural humility is different: an acknowledgement that you do not know, and a commitment to ask rather than assume. This theme practises the difference, and includes the one contextual skill that benefits from a specific drill — working with an interpreter.

  For the reasoning, see Chapter 8 of the handbook (§ 3 — Cultural Factors).

  1. Recognition — Humility vs. competence

  Goal

  Recognise the move that reflects cultural humility rather than claimed cultural expertise.

  Task

  A patient has told you they are Sikh. Which of these is cultural humility in action?

  • A) “I know Sikhs don’t cut hair — so I won’t need to shave the area.”
  • B) “Before we go ahead, is there anything about your beliefs or practices that I should know about for this procedure?”
  • C) “All my Sikh patients have been fine with this, so don’t worry.”
  • D) “I’ll use the standard approach; we can adjust if anything comes up.”

  Reveal answer

   

  ---

  2. Reformulation — From assumption to question

  Goal

  Rewrite an assumption as a question.

  Task

  A physician thinks: “She’s Muslim, so her husband probably makes the medical decisions.” The thought is about to shape how the rest of the consultation unfolds. Rewrite the assumption as the question that should go in its place.

  Reveal exemplar and feedback

  ---

  3. Apply to case — Working with an interpreter

  Goal

  Run a consultation through an interpreter, using the specific moves that keep the patient at the centre.

  Task

  You are seeing a patient whose first language is Somali. A professional interpreter is present in person. The patient is worried about chest pain. Write down three specific practices you will use while conducting this consultation. Then reveal.

  Reveal exemplars and feedback

  ---

  4. Spot-the-issue — Family as interpreter

  Goal

  Notice when a family member has been used as an interpreter for a consultation that needed a professional.

  Task

  Read this exchange. What has gone wrong?

  Physician (to the adult son who has accompanied his mother): Can you tell your mother that the biopsy showed cancer, but it’s at an early stage and there are good treatment options?
  Son: (speaks briefly to his mother in their language, then back to the physician) Yes, she understands.
  Physician: Does she have any questions?
  Son: She says no, thank you.
  Physician: Great.

  Reveal answer

  Theme 3 — Socioeconomic barriers

  Cost, time, housing, caregiving, chaotic work hours — the things that happen outside the consultation room shape what is possible inside it, and most are invisible unless you ask. This theme practises bringing social circumstances into the medical conversation without condescending, without stereotyping, and without missing them.

  For the reasoning, see Chapter 8 of the handbook (§ 4 — Socioeconomic Circumstances).

  1. Recognition — Social determinants as clinical data

  Goal

  Recognise a question that treats social context as clinically relevant rather than as a social nicety.

  Task

  You are about to start a patient on a medication that costs a significant amount monthly and must be taken twice daily with food. Which question best checks whether the plan will survive daily life?

  • A) “Any allergies?”
  • B) “Will you remember to take it?”
  • C) “Practically — how will this fit into your day? Cost, timing, meals, work — anything likely to get in the way?”
  • D) “Do you have any questions about the side effects?”

  Reveal answer

  ---

  2. Reformulation — Adherence advice without condescension

  Goal

  Rewrite a treatment instruction so it adapts to the patient’s real circumstances without sounding patronising.

  Task

  A patient has told you they work night shifts and live with their elderly mother whom they care for. The current instruction: “Try to take this with breakfast every morning and get plenty of rest.” Rewrite it so it fits the patient’s life, without treating their circumstances as a problem to fix.

  Reveal exemplar and feedback

  ---

  3. Spot-the-issue — A stereotype in action

  Goal

  Notice when an adaptation has tipped into stereotyping.

  Task

  Read this exchange. What has the physician done?

  Patient: I’ve been told I need the statin. Can I afford that?
  Physician: Don’t worry — looking at your situation, I’ll put you on the cheapest generic and we’ll see how you go. Most people in your position find that works out.
  Patient: … my situation?
  Physician: I just meant, you know, keeping costs down is important.

  Reveal answer

  Theme 4 — Navigating difficult consultations

  Some consultations are hard not because of literacy, culture, or money but because of what is happening between you and the patient — anger, bad news, a request you cannot grant, symptoms no test explains. These lean hardest on the process skills. This theme practises the moves, and closes the chapter with a reflection on what adapting to all of these contexts teaches you.

  For the reasoning, see Chapter 8 of the handbook (§ 7 — Difficult Consultations).

  1. Recognition — Responding to anger

  Goal

  Choose the response most likely to de-escalate an angry patient.

  Task

  A patient is angry about a long wait. Which response is most likely to take the heat out of the exchange?

  • A) “There’s nothing I can do about the waiting times.”
  • B) “I can see you’re frustrated — help me understand what’s happened.”
  • C) “Please calm down so we can talk.”
  • D) “You’re not the only one who’s been waiting.”

  Reveal answer

  ---

  2. Reformulation — Saying no with empathy

  Goal

  Turn a flat refusal into one the patient can accept.

  Task

  A patient with a viral illness asks for antibiotics. Rewrite a bare “No, you don’t need antibiotics” into a refusal that leads with empathy, gives the reason, and offers an alternative. Then reveal.

  Reveal exemplar and feedback

  ---

  3. Spot-the-issue — Breaking bad news

  Goal

  Notice what goes wrong when bad news is delivered without space.

  Task

  Read this. What has the physician got wrong?

  Physician: So the scan shows it has spread to the liver, which is why we’ll start chemotherapy next week, and you’ll need blood tests first, and the oncologist will go through the options…
  Patient: (silent, pale)
  Physician: … and we’ll sort out the appointments today.

  Reveal answer

  ---

  4. Apply to case — Unexplained symptoms

  Goal

  Hold a consultation where the tests are normal but the suffering is real.

  Task

  A patient has months of fatigue and pain. The tests are normal, no diagnosis fits, and they have seen several doctors. Write two moves: one that validates, and one that shifts the work usefully. Then reveal.

  Reveal answer and feedback

  ---

  5. Reflection — Your reactions, and what adaptation teaches

  Goal

  Name your own defaults and reactions — and what working across contexts will teach you.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Name a patient or situation that triggers a reaction in you — frustration, dread, the sinking feeling at a name on the list. What is the reaction telling you, about them or about you?
  2. Name one time you caught yourself assuming something about a patient’s context — literacy, culture, money — from something you saw, heard, or read in the chart.
  3. Of all the adaptations in this chapter — literacy, culture, socioeconomic, the difficult consultation — which feels hardest, and why?
  4. What is one small thing you want to try in your next challenging consultation?

  Reveal reflection

  That completes Chapter 8. You have now worked through the skills of the consultation and the contexts that shape how they land. One chapter remains — on how the MAAS skills sit inside education, assessment, and the longer life of a professional.

• 8.2Theme 2 — Cultural humility

  Cultural competence sounds like expertise — a body of knowledge about this group and that practice. Cultural humility is different: an acknowledgement that you do not know, and a commitment to ask rather than assume. This theme practises the difference, and includes the one contextual skill that benefits from a specific drill — working with an interpreter.

  For the reasoning, see Chapter 8 of the handbook (§ 3 — Cultural Factors).

  1. Recognition — Humility vs. competence

  Goal

  Recognise the move that reflects cultural humility rather than claimed cultural expertise.

  Task

  A patient has told you they are Sikh. Which of these is cultural humility in action?

  • A) “I know Sikhs don’t cut hair — so I won’t need to shave the area.”
  • B) “Before we go ahead, is there anything about your beliefs or practices that I should know about for this procedure?”
  • C) “All my Sikh patients have been fine with this, so don’t worry.”
  • D) “I’ll use the standard approach; we can adjust if anything comes up.”

  Reveal answer

  B is cultural humility. It asks. A applies a general rule to an individual who may or may not hold it (some Sikhs do cut hair; many do not have strong feelings about body hair specifically; this patient’s own practice may differ from the group norm). C generalises from one set of patients to another. D postpones the question until something is already wrong. Humility does not mean learning nothing about cultures; it means treating cultural knowledge as a prompt to ask, not as an answer about the person in front of you. (MAAS — cultural humility)

  ---

  2. Reformulation — From assumption to question

  Goal

  Rewrite an assumption as a question.

  Task

  A physician thinks: “She’s Muslim, so her husband probably makes the medical decisions.” The thought is about to shape how the rest of the consultation unfolds. Rewrite the assumption as the question that should go in its place.

  Reveal exemplar and feedback

  Exemplars:

  • “When you’re making medical decisions, who would you want to be part of that conversation — is there anyone you’d like me to include?”
  • “Different families make medical decisions differently. How do you like to make these kinds of decisions — on your own, with family, with anyone else?”
  • “Is there anyone else you’d want to be part of this conversation, now or later?”

  Compare yours with the exemplars. Each one asks the patient directly, without pre-naming an answer. The risk of the original assumption is not that it is always wrong — for some Muslim families it will match the reality — but that it preempts the patient’s own statement of how she wants to decide. An assumption, even a statistically reasonable one, closes the door the question would have kept open. (MAAS — cultural humility in practice)

  ---

  3. Apply to case — Working with an interpreter

  Goal

  Run a consultation through an interpreter, using the specific moves that keep the patient at the centre.

  Task

  You are seeing a patient whose first language is Somali. A professional interpreter is present in person. The patient is worried about chest pain. Write down three specific practices you will use while conducting this consultation. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • Speak to and look at the patient, not the interpreter. Address your questions to the patient in first person (“How long has the pain been there?”) rather than “Ask her how long the pain has been there.”
  • Keep your sentences short and pause for the interpretation. Long paragraphs get compressed or reshaped; short sentences survive translation.
  • Brief the interpreter before the consultation. A thirty-second brief on what you are trying to establish, and agreement that the interpreter will render everything the patient says (including hesitations), not summarise.

  Compare yours with the exemplars. Other practices that matter: do not use family members, including adult children, as interpreters for anything clinically meaningful — confidentiality, accuracy, and the power dynamic inside the family all suffer. If the hospital or practice has ad-hoc bilingual staff, trained professional interpreters are still preferable for anything beyond short practical interactions. Interpreter work is one of the few contextual skills where a real encounter is where the learning mostly lives — these principles are a starting scaffold. (MAAS — working with interpreters)

  ---

  4. Spot-the-issue — Family as interpreter

  Goal

  Notice when a family member has been used as an interpreter for a consultation that needed a professional.

  Task

  Read this exchange. What has gone wrong?

  Physician (to the adult son who has accompanied his mother): Can you tell your mother that the biopsy showed cancer, but it’s at an early stage and there are good treatment options?
  Son: (speaks briefly to his mother in their language, then back to the physician) Yes, she understands.
  Physician: Does she have any questions?
  Son: She says no, thank you.
  Physician: Great.

  Reveal answer

  A professional interpreter should be present for a conversation this clinically and emotionally significant. Using the adult son has several problems at once: accuracy (we have no way of knowing what he told his mother — he may have softened, omitted, or reframed); confidentiality (the mother has had no opportunity to speak privately); power (she cannot ask her son a question she does not want him to know she has); and carer burden (he is now carrying his mother’s diagnosis before he has processed it himself). The physician’s “great” closes the consultation on an answer that may not be the mother’s at all. This is one of the clearest cases in the chapter where an adaptation (use a professional interpreter) is not optional. (Feedback Index: Interpreter Use)

  Theme 3 — Socioeconomic barriers

  Cost, time, housing, caregiving, chaotic work hours — the things that happen outside the consultation room shape what is possible inside it, and most are invisible unless you ask. This theme practises bringing social circumstances into the medical conversation without condescending, without stereotyping, and without missing them.

  For the reasoning, see Chapter 8 of the handbook (§ 4 — Socioeconomic Circumstances).

  1. Recognition — Social determinants as clinical data

  Goal

  Recognise a question that treats social context as clinically relevant rather than as a social nicety.

  Task

  You are about to start a patient on a medication that costs a significant amount monthly and must be taken twice daily with food. Which question best checks whether the plan will survive daily life?

  • A) “Any allergies?”
  • B) “Will you remember to take it?”
  • C) “Practically — how will this fit into your day? Cost, timing, meals, work — anything likely to get in the way?”
  • D) “Do you have any questions about the side effects?”

  Reveal answer

  ---

  2. Reformulation — Adherence advice without condescension

  Goal

  Rewrite a treatment instruction so it adapts to the patient’s real circumstances without sounding patronising.

  Task

  A patient has told you they work night shifts and live with their elderly mother whom they care for. The current instruction: “Try to take this with breakfast every morning and get plenty of rest.” Rewrite it so it fits the patient’s life, without treating their circumstances as a problem to fix.

  Reveal exemplar and feedback

  ---

  3. Spot-the-issue — A stereotype in action

  Goal

  Notice when an adaptation has tipped into stereotyping.

  Task

  Read this exchange. What has the physician done?

  Patient: I’ve been told I need the statin. Can I afford that?
  Physician: Don’t worry — looking at your situation, I’ll put you on the cheapest generic and we’ll see how you go. Most people in your position find that works out.
  Patient: … my situation?
  Physician: I just meant, you know, keeping costs down is important.

  Reveal answer

  Theme 4 — Navigating difficult consultations

  Some consultations are hard not because of literacy, culture, or money but because of what is happening between you and the patient — anger, bad news, a request you cannot grant, symptoms no test explains. These lean hardest on the process skills. This theme practises the moves, and closes the chapter with a reflection on what adapting to all of these contexts teaches you.

  For the reasoning, see Chapter 8 of the handbook (§ 7 — Difficult Consultations).

  1. Recognition — Responding to anger

  Goal

  Choose the response most likely to de-escalate an angry patient.

  Task

  A patient is angry about a long wait. Which response is most likely to take the heat out of the exchange?

  • A) “There’s nothing I can do about the waiting times.”
  • B) “I can see you’re frustrated — help me understand what’s happened.”
  • C) “Please calm down so we can talk.”
  • D) “You’re not the only one who’s been waiting.”

  Reveal answer

  ---

  2. Reformulation — Saying no with empathy

  Goal

  Turn a flat refusal into one the patient can accept.

  Task

  A patient with a viral illness asks for antibiotics. Rewrite a bare “No, you don’t need antibiotics” into a refusal that leads with empathy, gives the reason, and offers an alternative. Then reveal.

  Reveal exemplar and feedback

  ---

  3. Spot-the-issue — Breaking bad news

  Goal

  Notice what goes wrong when bad news is delivered without space.

  Task

  Read this. What has the physician got wrong?

  Physician: So the scan shows it has spread to the liver, which is why we’ll start chemotherapy next week, and you’ll need blood tests first, and the oncologist will go through the options…
  Patient: (silent, pale)
  Physician: … and we’ll sort out the appointments today.

  Reveal answer

  ---

  4. Apply to case — Unexplained symptoms

  Goal

  Hold a consultation where the tests are normal but the suffering is real.

  Task

  A patient has months of fatigue and pain. The tests are normal, no diagnosis fits, and they have seen several doctors. Write two moves: one that validates, and one that shifts the work usefully. Then reveal.

  Reveal answer and feedback

  ---

  5. Reflection — Your reactions, and what adaptation teaches

  Goal

  Name your own defaults and reactions — and what working across contexts will teach you.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Name a patient or situation that triggers a reaction in you — frustration, dread, the sinking feeling at a name on the list. What is the reaction telling you, about them or about you?
  2. Name one time you caught yourself assuming something about a patient’s context — literacy, culture, money — from something you saw, heard, or read in the chart.
  3. Of all the adaptations in this chapter — literacy, culture, socioeconomic, the difficult consultation — which feels hardest, and why?
  4. What is one small thing you want to try in your next challenging consultation?

  Reveal reflection

  That completes Chapter 8. You have now worked through the skills of the consultation and the contexts that shape how they land. One chapter remains — on how the MAAS skills sit inside education, assessment, and the longer life of a professional.

• 8.3Theme 3 — Socioeconomic barriers

  Cost, time, housing, caregiving, chaotic work hours — the things that happen outside the consultation room shape what is possible inside it, and most are invisible unless you ask. This theme practises bringing social circumstances into the medical conversation without condescending, without stereotyping, and without missing them.

  For the reasoning, see Chapter 8 of the handbook (§ 4 — Socioeconomic Circumstances).

  1. Recognition — Social determinants as clinical data

  Goal

  Recognise a question that treats social context as clinically relevant rather than as a social nicety.

  Task

  You are about to start a patient on a medication that costs a significant amount monthly and must be taken twice daily with food. Which question best checks whether the plan will survive daily life?

  • A) “Any allergies?”
  • B) “Will you remember to take it?”
  • C) “Practically — how will this fit into your day? Cost, timing, meals, work — anything likely to get in the way?”
  • D) “Do you have any questions about the side effects?”

  Reveal answer

  C treats social context as clinical data. It opens four likely failure points at once — cost, timing, meals, work — and invites the patient to name which one matters for them. A and D are safety checks. B is an implied judgement of character rather than a question about the patient’s circumstances. The move in C is why social determinants belong inside the consultation, not beside it: a treatment plan built without them is a plan for a patient who does not exist. (MAAS 3.10 · social determinants)

  ---

  2. Reformulation — Adherence advice without condescension

  Goal

  Rewrite a treatment instruction so it adapts to the patient’s real circumstances without sounding patronising.

  Task

  A patient has told you they work night shifts and live with their elderly mother whom they care for. The current instruction: “Try to take this with breakfast every morning and get plenty of rest.” Rewrite it so it fits the patient’s life, without treating their circumstances as a problem to fix.

  Reveal exemplar and feedback

  Exemplar:

  “This tablet works best taken with a meal. For you, that might be whatever meal you have just before or after your shift rather than breakfast specifically. Have a think about when that would be — and then we can decide together what makes sense.”

  Compare yours with the exemplar. The original assumed a standard daytime pattern. The exemplar keeps the clinical requirement (with a meal) but adapts the framing (whatever meal makes sense for a night-shift life). Notice what is not there: no suggestion that the patient should rearrange their life, no implication that their circumstances are a barrier to overcome. The patient’s life is the frame; the advice adapts into it. This is the difference between adaptation and accommodation. (MAAS 3.11)

  ---

  3. Spot-the-issue — A stereotype in action

  Goal

  Notice when an adaptation has tipped into stereotyping.

  Task

  Read this exchange. What has the physician done?

  Patient: I’ve been told I need the statin. Can I afford that?
  Physician: Don’t worry — looking at your situation, I’ll put you on the cheapest generic and we’ll see how you go. Most people in your position find that works out.
  Patient: … my situation?
  Physician: I just meant, you know, keeping costs down is important.

  Reveal answer

  The physician has made an assumption about the patient’s financial circumstances from cues that were not named — and the patient noticed. “Your situation” tried to be considerate but landed as a judgement. The clinical response (the generic statin) may be right; the problem is the reasoning was not based on what the patient told you. The fix is to ask: “Can I ask what your situation is with medication costs — do you have a prepayment certificate, or are there worries on that side I should factor in?” Adaptation is kind. Assumption about social class, race, education, or neighbourhood is stereotyping, even when the conclusion would have been the same. The difference is whether the patient had a say. (Feedback Index: Avoiding Assumptions)

• 8.4Theme 4 — Navigating difficult consultations

  Some consultations are hard not because of literacy, culture, or money but because of what is happening between you and the patient — anger, bad news, a request you cannot grant, symptoms no test explains. These lean hardest on the process skills. This theme practises the moves, and closes the chapter with a reflection on what adapting to all of these contexts teaches you.

  For the reasoning, see Chapter 8 of the handbook (§ 7 — Difficult Consultations).

  1. Recognition — Responding to anger

  Goal

  Choose the response most likely to de-escalate an angry patient.

  Task

  A patient is angry about a long wait. Which response is most likely to take the heat out of the exchange?

  • A) “There’s nothing I can do about the waiting times.”
  • B) “I can see you’re frustrated — help me understand what’s happened.”
  • C) “Please calm down so we can talk.”
  • D) “You’re not the only one who’s been waiting.”

  Reveal answer

  B does two things at once: it names the emotion, so the patient feels heard, and it opens the specific cause. A defends the system, C orders the feeling away (which usually inflames it), and D dismisses. Anger usually rides on fear, frustration, or not being heard; meeting it with a calm voice and genuine curiosity does more than any argument about whether the anger is justified. (MAAS B — responding to emotion; Feedback Index: De-escalation)

  ---

  2. Reformulation — Saying no with empathy

  Goal

  Turn a flat refusal into one the patient can accept.

  Task

  A patient with a viral illness asks for antibiotics. Rewrite a bare “No, you don’t need antibiotics” into a refusal that leads with empathy, gives the reason, and offers an alternative. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  “I can see you want to get better as fast as possible. I can’t prescribe antibiotics here, because they won’t work against this kind of infection and could give you side effects — but let me tell you what will help, and what to watch for if things change.”

  Compare yours with the exemplar. The order is what makes it work: acknowledge the hope first, explain the why, then offer what you can do, so the patient leaves with something to act on rather than a bare refusal. A “no” that explores the request first (“help me understand what you were hoping that would do”) lands even better, because there is often a concern underneath you can meet another way. (MAAS 3.1, B — empathy)

  ---

  3. Spot-the-issue — Breaking bad news

  Goal

  Notice what goes wrong when bad news is delivered without space.

  Task

  Read this. What has the physician got wrong?

  Physician: So the scan shows it has spread to the liver, which is why we’ll start chemotherapy next week, and you’ll need blood tests first, and the oncologist will go through the options…
  Patient: (silent, pale)
  Physician: … and we’ll sort out the appointments today.

  Reveal answer

  Two things. There was no warning shot — the news arrived mid-sentence, with nothing to let the patient brace — and it was buried in logistics. And there was no pause: the physician kept talking through the patient’s shock, when almost nothing said after the news will register. The shape that works is the opposite: a warning shot (“I’m afraid I have difficult news”), the news in one plain sentence, then silence — and responding to the emotion before any next steps, which can wait until the patient is ready to hear them. (MAAS — breaking bad news; SPIKES; Feedback Index: Bad news)

  ---

  4. Apply to case — Unexplained symptoms

  Goal

  Hold a consultation where the tests are normal but the suffering is real.

  Task

  A patient has months of fatigue and pain. The tests are normal, no diagnosis fits, and they have seen several doctors. Write two moves: one that validates, and one that shifts the work usefully. Then reveal.

  Reveal answer and feedback

  Validate: “I can see this is real and affecting your life” — with no hint that they are imagining it. Shift to function: “We haven’t found a clear cause, which I know is frustrating; that does not mean nothing is wrong. Let’s focus on getting you functioning better while we keep watching.” These patients are used to being doubted, so the validation is not a courtesy but the thing that lets the consultation work at all — and function is something you can help with even before a diagnosis, if one ever comes. (MAAS — unexplained symptoms; Ch2 functional impact)

  ---

  5. Reflection — Your reactions, and what adaptation teaches

  Goal

  Name your own defaults and reactions — and what working across contexts will teach you.

  Task

  Take five minutes with these prompts. Write them down for yourself — there is no answer key.

  1. Name a patient or situation that triggers a reaction in you — frustration, dread, the sinking feeling at a name on the list. What is the reaction telling you, about them or about you?
  2. Name one time you caught yourself assuming something about a patient’s context — literacy, culture, money — from something you saw, heard, or read in the chart.
  3. Of all the adaptations in this chapter — literacy, culture, socioeconomic, the difficult consultation — which feels hardest, and why?
  4. What is one small thing you want to try in your next challenging consultation?

  Reveal reflection

  This exercise has no answer key. What matters is that you can name your own defaults, and the reactions that come up when a consultation is hard.

  Those reactions are information — about you as much as about the patient — and naming them quietly to yourself is what keeps them from leaking into the room; you can give good care while frustrated, but only if you know that you are. Context work is never neutral: every physician carries assumptions built from their own life, training, and patient population, and patients tend to notice them before you do. One measure of growth is that you start to notice them too, preferably before you act. The universal moves — plain language, teach-back, ask rather than assume, name the emotion — are there because they work across circumstances, and because they release you from the impossible task of reading each patient’s needs from the outside. (MAAS — universal design)

  That completes Chapter 8. You have now worked through the skills of the consultation and the contexts that shape how they land. One chapter remains — on how the MAAS skills sit inside education, assessment, and the longer life of a professional.

9Chapter 9. Education & Assessment

• 9.1Theme 1 — Deliberate practice in MAAS

  Skills like the ones in this course do not settle into place through a single workshop or a final assessment. They build through deliberate, repeated practice, honest observation, and what seniors actually do — not what they say. This theme practises how skills really get built and made to stick.

  For the reasoning, see Chapter 9 of the handbook (§ 2 — Deliberate Practice).

  1. Recognition — What builds a lasting skill?

  Goal

  Recognise the learning conditions under which communication skills actually become durable.

  Task

  Which of these is most likely to produce lasting improvement in a student’s consultation skills?

  • A) A two-day intensive workshop at the start of the academic year.
  • B) One OSCE at the end of each term.
  • C) Weekly observed consultations across the year, with targeted feedback after each.
  • D) Reading the handbook twice.

  Reveal answer

  C. The evidence is consistent: skills decay after single-event training, are poorly calibrated by end-of-term testing alone, and do not transfer from reading. What works is repeated observed practice with specific feedback over time. A generates confidence without staying power. B rewards cramming for the OSCE. D gives knowledge, not skill. The implication is uncomfortable: if your course offers only A, B, or D, the lasting learning will come from what you arrange for yourself — peer observation, reflection after real consultations, and asking supervisors to watch and comment. (MAAS — longitudinal practice)

  ---

  2. Spot-the-issue — The modelling problem

  Goal

  Notice when what seniors do contradicts what they teach, and what that does to learning.

  Task

  Read this short observation. What is likely to happen to the student’s practice?

  In a morning lecture, the senior registrar teaches Y2 students about bookending a consultation — “Always ask ‘is there something else?’ at the start and at the close.” That afternoon, the same registrar takes the students on the ward round. In fourteen consecutive patient interactions, she does not ask the question once. At the end of the round, she says, “That’s how it’s done in real life — you’ll get quicker.”

  Reveal answer

  Within weeks, the students will drop the bookend move in their own consultations. The lecture content will survive as something they could write on an exam; the behaviour will not survive because what they saw modelled was its absence. This is the modelling problem: learners absorb the observable behaviour of their seniors more durably than the explicit teaching, especially when the two conflict. The fix is not to blame the registrar; it is to know that what your seniors do is part of your curriculum, and to decide deliberately what you are willing to model on and what you are not. A junior who keeps the bookends even when the registrar has dropped them is doing the harder and more lasting work. (Feedback Index: Modelling)

  ---

  3. Commit-then-compare — How you will keep practising

  Goal

  Plan how you will sustain these skills after the course ends.

  Task

  Write down two concrete things you will do, in the next four weeks, to keep these skills growing. One should involve another person. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “Ask one classmate to watch a clinic consultation and mark two MAAS items on a pocket card.”
  • “After every consultation I lead, write one sentence: what did I do well, what would I do differently?”
  • “Record (with permission) one simulated-patient session this month and re-watch it the next day with a checklist.”
  • “Pair up with a colleague for fortnightly peer observation — twenty minutes each, two items chosen in advance.”

  Compare your two with the exemplars. Notice that the ones most likely to work share three features: they are specific (a named activity, not “try harder”), they are small (fit into a real week), and they involve another person’s eye. The single best predictor of whether these skills survive is whether you have created a small, regular arrangement for someone else to see you work. (MAAS — sustained practice)

  Theme 2 — Seeking and using feedback

  Feedback is the engine of clinical development. Done well, it moves a learner forward in days that reading and practising alone cannot match in months. Done badly, it makes learners defensive, cautious, or numb. This theme practises what effective feedback looks like, how to receive it without defending, and how to use the MAAS items you have learned as a shared vocabulary for peer feedback.

  For the reasoning, see Chapter 9 of the handbook (§ 4 — Feedback That Works).

  1. Recognition — What makes feedback useful?

  Goal

  Recognise the features of feedback that actually move a learner forward.

  Task

  Which of these is the most useful piece of feedback after an observed consultation?

  • A) “Overall, good job — you’ve got a nice manner.”
  • B) “You seemed rushed.”
  • C) “I noticed you moved to treatment before exploring the patient’s concerns — at about five minutes in. Try asking ‘what were you hoping for?’ before you propose anything next time.”
  • D) “Be more empathic.”

  Reveal answer

  C is the useful one. It is specific (a named moment: five minutes in), behavioural (the move: treatment before exploration), and actionable (what to do next time: one question before proposing). A is generic praise — pleasant but useless for learning. B is specific but not actionable. D is a trait, not a behaviour — the learner cannot do anything specific with it. The test of feedback is whether it tells the learner exactly what to try next time. (MAAS — feedback quality)

  ---

  2. Reformulation — From vague to specific

  Goal

  Rewrite a vague piece of feedback so the learner can act on it.

  Task

  A tutor has said to a junior: “Your consultation felt a bit cold.” Rewrite the feedback so it points to a named moment, a specific behaviour, and a concrete next step.

  Reveal exemplar and feedback

   

   

   

  ---

  3. Reformulation — From defensive to receptive

  Goal

  Rewrite a defensive response to feedback as a receptive one.

  Task

  A tutor tells a student: “You moved to solutions before you’d finished exploring the problem.” The student’s reply: “Well, the clinic was running late, and the patient was quite straightforward, so I thought…” Rewrite the reply as a receptive one.

  Reveal exemplar and feedback

  ---

  4. Commit-then-compare — Using MAAS items as shared vocabulary

  Goal

  Translate generic peer feedback into MAAS-item language, and write feedback for a peer using item numbers.

  Task

  Imagine you have just observed a classmate’s consultation. Your instinct is to say: “Your opening was good, but you felt rushed in the middle, and the patient seemed confused by your explanation.”

  Now rewrite each of the three observations above using a specific MAAS item (or two) and a brief explanation. Then reveal.

  Reveal exemplars and feedback

  Theme 3 — Self-assessment with MAAS-GP-Self

  You will not always have an observer. Learning to judge your own consultations honestly is what keeps you developing once the course and the supervised years are behind you. The catch is that general self-assessment is unreliable—we are poor judges of our own performance in the abstract. It becomes reliable when it is anchored to clear criteria, which is exactly what MAAS-GP-Self provides. This theme practises using it, and reading the gap between how you see yourself and how an observer does.

  For the reasoning, see Chapter 9 of the handbook (§ 5 — Assessment Approaches · § 6 — The MAAS Ecosystem).

  1. Recognition — Why self-assessment needs criteria

  Goal

  Recognise the condition under which self-assessment becomes trustworthy.

  Task

  Self-assessment is famously unreliable—except under one condition. Which is most likely to be accurate?

  • A) Asking yourself “How did I do?” after the consultation.
  • B) A general sense that it “went well.”
  • C) Scoring your own (recorded) consultation against defined, behaviourally-anchored items—MAAS-GP-Self.
  • D) Comparing how you feel today with how you felt last week.

  Reveal answer

  ---

  2. Apply to case — The self–observer gap

  Goal

  Read the gap between your self-score and an observer’s score as information.

  Task

  You score a consultation on MAAS-GP-Self; your supervisor scores the same consultation on MAAS-GP. Your scores are markedly higher than theirs. What does the gap most usefully tell you, and what would you do? Then reveal.

  Reveal answer and feedback

  ---

  3. Apply to case — Self-scoring on video

  Goal

  Turn an uncomfortable re-watch into structured learning.

  Task

  You have a recording of one of your consultations. Rather than watch it vaguely, write down how you would make it a real self-assessment. Then reveal.

  Reveal exemplar and feedback

  ---

  4. Reflection — Your likely blind spots

  Goal

  Name where your self-view and an observer’s are most likely to diverge.

  Task

  Name two MAAS items you suspect you rate yourself more generously on than an observer would. Write them down—there is no answer key.

  Reveal reflection

  Theme 4 — Designing your learning plan

  Your development is, in the end, yours to drive. Teachers and programmes help, but they do not run it. This theme practises taking ownership—building a focused plan, keeping yourself sharp by teaching others—and closes with a reflection on where your development goes from here, and a short farewell.

  For the reasoning, see Chapter 9 of the handbook (§ 8 — Building Your Own Development).

  1. Recognition — Taking ownership

  Goal

  Recognise the most reliable way to find your next learning goal.

  Task

  Your training will not always hand you your next goal. What is the most reliable way to find the one skill to work on next?

  • A) Wait for your tutor to tell you at the end-of-term review.
  • B) Guess, from which consultations felt uncomfortable.
  • C) Ask for specific feedback on a named area, and check it against your own self-assessment.
  • D) Work on whatever the last lecture happened to cover.

  Reveal answer

  ---

  2. Commit-then-compare — Design your plan

  Goal

  Build a concrete, four-week plan for one skill.

  Task

  Choose one MAAS skill you want to improve. Write a four-week plan: the specific skill, how you will practise it deliberately, who will give you specific feedback, and how you will know it is improving. Then reveal.

  Reveal exemplar and feedback

  ---

  3. Apply to case — Teaching a junior

  Goal

  Use a teaching moment with a junior colleague to reinforce your own skills.

  Task

  You are three years into practice. A medical student shadowing you says after a consultation: “I noticed you asked ‘is there something else?’ twice — at the start and the end. Why do you do that?” Write down your one-minute explanation. Then reveal.

  Reveal exemplar and feedback

  ---

  4. Reflection — Where your development goes next

  Goal

  Name, in your own words, what you will carry forward from this chapter and the course.

  Task

  Take a few minutes with these four prompts. Write them down for yourself—there is no answer key.

  1. Name one feedback conversation (given or received) that you want to do differently in the next month.
  2. Name one person—a peer, a tutor, a future colleague—you would like to have observing you regularly, and one specific thing you would like them to watch for.
  3. When you imagine yourself ten years into practice, what move from this course do you hope is still part of how you consult?
  4. What, honestly, worries you about keeping these skills as your training intensifies? Name it—the naming is the first half of protecting against it.

  Reveal reflection

  End of MAAS-PREP

  You have worked through the whole course—exploring Reasons for Encounter, history-taking, review of systems, presenting solutions, the process skills that hold it all together, the flow of a single consultation, the arc of a patient over time, the contexts that shape every visit, and the development that will carry you forward. That is a lot of small moves, most of them invisible to patients and essential to them at the same time.

  The course ends here. The practice does not. Keep a pocket of these exercises for a slow afternoon or the week before an OSCE. Bring the item vocabulary into your peer feedback sessions. Notice, from time to time, which moves still feel mechanical and which have become yours. And when a patient tells you something they have not told anyone else, notice that too—it is usually the skills in this course, more than the clinical knowledge, that have made the difference.

  Thank you for working through this with us. We hope it serves you well.

  — Crijnen & Kraan

• 9.2Theme 2 — Seeking and using feedback

  Feedback is the engine of clinical development. Done well, it moves a learner forward in days that reading and practising alone cannot match in months. Done badly, it makes learners defensive, cautious, or numb. This theme practises what effective feedback looks like, how to receive it without defending, and how to use the MAAS items you have learned as a shared vocabulary for peer feedback.

  For the reasoning, see Chapter 9 of the handbook (§ 4 — Feedback That Works).

  1. Recognition — What makes feedback useful?

  Goal

  Recognise the features of feedback that actually move a learner forward.

  Task

  Which of these is the most useful piece of feedback after an observed consultation?

  • A) “Overall, good job — you’ve got a nice manner.”
  • B) “You seemed rushed.”
  • C) “I noticed you moved to treatment before exploring the patient’s concerns — at about five minutes in. Try asking ‘what were you hoping for?’ before you propose anything next time.”
  • D) “Be more empathic.”

  Reveal answer

  C is the useful one. It is specific (a named moment: five minutes in), behavioural (the move: treatment before exploration), and actionable (what to do next time: one question before proposing). A is generic praise — pleasant but useless for learning. B is specific but not actionable. D is a trait, not a behaviour — the learner cannot do anything specific with it. The test of feedback is whether it tells the learner exactly what to try next time. (MAAS — feedback quality)

  ---

  2. Reformulation — From vague to specific

  Goal

  Rewrite a vague piece of feedback so the learner can act on it.

  Task

  A tutor has said to a junior: “Your consultation felt a bit cold.” Rewrite the feedback so it points to a named moment, a specific behaviour, and a concrete next step.

  Reveal exemplar and feedback

  Exemplar:

  “When the patient said her father had died of the same condition, you moved straight to the next history question — I noticed you didn’t reflect what she’d told you. Next time, try a one-line reflection before you move on — something like ‘that must be hard to carry into this consultation.’ That’s the reflecting-emotions move from item B.2.”

  Compare yours with the exemplar. Three moves: named moment (the father’s death), specific behaviour (moving on without reflecting), actionable next step (a one-line reflection, with an example). Ending with the item tag (B.2) gives the learner a place to look things up and practise. “Felt cold” could not be acted on; this version can. (MAAS — feedback quality)

  ---

  3. Reformulation — From defensive to receptive

  Goal

  Rewrite a defensive response to feedback as a receptive one.

  Task

  A tutor tells a student: “You moved to solutions before you’d finished exploring the problem.” The student’s reply: “Well, the clinic was running late, and the patient was quite straightforward, so I thought…” Rewrite the reply as a receptive one.

  Reveal exemplar and feedback

  Exemplar:

  “Yes — I can see that. Can you show me the exact moment? And can you tell me what I might have missed by moving on when I did?”

  Compare yours with the exemplar. Two moves: acknowledging the feedback (“yes — I can see that”), and asking for more specifics (“show me the moment”, “what might I have missed?”). The defensive reply does three things that block learning at once: it offers reasons, shifts attention to circumstances, and tells the tutor the reply is complete. The receptive reply does the opposite: it accepts the observation, invites detail, and keeps the door open. The instinct to explain yourself is natural; the practice is to let it pass. (MAAS — receiving feedback)

  ---

  4. Commit-then-compare — Using MAAS items as shared vocabulary

  Goal

  Translate generic peer feedback into MAAS-item language, and write feedback for a peer using item numbers.

  Task

  Imagine you have just observed a classmate’s consultation. Your instinct is to say: “Your opening was good, but you felt rushed in the middle, and the patient seemed confused by your explanation.”

  Now rewrite each of the three observations above using a specific MAAS item (or two) and a brief explanation. Then reveal.

  Reveal exemplars and feedback

  Exemplars:

  • “Your opening was good” → “Your opening was open and inviting — that’s item 1.1, asking the reason for the visit. You also caught the full agenda with the ‘something else?’ move, which is item A.2. The patient named three concerns because of it.”
  • “You felt rushed in the middle” → “At around four minutes, I noticed the pace got fast — three quick questions without pausing. That’s item B.9, setting a pace the patient can match. A short pause, or a quick summary of what you’d heard (that would be item C.3), would have given the consultation room to breathe.”
  • “The patient seemed confused” → “Your explanation at the end had a lot in it. A check-in to see what landed — item C.5, verifying understanding — would have told you what was clear and what wasn’t. Try something like: ‘what will you tell your partner about this tonight?’”

  Compare yours with the exemplars. Notice that each one names what the skill is, not only its number. The number is a shortcut for later — a place to look up the exemplars and the handbook section — but the feedback itself stays in human language. “Item B.9” on its own sounds like a code; “the pace move, item B.9” is warm and clear at once. The point of the item numbers is not to replace ordinary words — it is to give you a shared map you can both find your way around. Bring this vocabulary, and this way of using it, into your observed sessions. (MAAS — shared vocabulary)

  Theme 3 — Self-assessment with MAAS-GP-Self

  You will not always have an observer. Learning to judge your own consultations honestly is what keeps you developing once the course and the supervised years are behind you. The catch is that general self-assessment is unreliable—we are poor judges of our own performance in the abstract. It becomes reliable when it is anchored to clear criteria, which is exactly what MAAS-GP-Self provides. This theme practises using it, and reading the gap between how you see yourself and how an observer does.

  For the reasoning, see Chapter 9 of the handbook (§ 5 — Assessment Approaches · § 6 — The MAAS Ecosystem).

  1. Recognition — Why self-assessment needs criteria

  Goal

  Recognise the condition under which self-assessment becomes trustworthy.

  Task

  Self-assessment is famously unreliable—except under one condition. Which is most likely to be accurate?

  • A) Asking yourself “How did I do?” after the consultation.
  • B) A general sense that it “went well.”
  • C) Scoring your own (recorded) consultation against defined, behaviourally-anchored items—MAAS-GP-Self.
  • D) Comparing how you feel today with how you felt last week.

  Reveal answer

  ---

  2. Apply to case — The self–observer gap

  Goal

  Read the gap between your self-score and an observer’s score as information.

  Task

  You score a consultation on MAAS-GP-Self; your supervisor scores the same consultation on MAAS-GP. Your scores are markedly higher than theirs. What does the gap most usefully tell you, and what would you do? Then reveal.

  Reveal answer and feedback

  ---

  3. Apply to case — Self-scoring on video

  Goal

  Turn an uncomfortable re-watch into structured learning.

  Task

  You have a recording of one of your consultations. Rather than watch it vaguely, write down how you would make it a real self-assessment. Then reveal.

  Reveal exemplar and feedback

  ---

  4. Reflection — Your likely blind spots

  Goal

  Name where your self-view and an observer’s are most likely to diverge.

  Task

  Name two MAAS items you suspect you rate yourself more generously on than an observer would. Write them down—there is no answer key.

  Reveal reflection

  Theme 4 — Designing your learning plan

  Your development is, in the end, yours to drive. Teachers and programmes help, but they do not run it. This theme practises taking ownership—building a focused plan, keeping yourself sharp by teaching others—and closes with a reflection on where your development goes from here, and a short farewell.

  For the reasoning, see Chapter 9 of the handbook (§ 8 — Building Your Own Development).

  1. Recognition — Taking ownership

  Goal

  Recognise the most reliable way to find your next learning goal.

  Task

  Your training will not always hand you your next goal. What is the most reliable way to find the one skill to work on next?

  • A) Wait for your tutor to tell you at the end-of-term review.
  • B) Guess, from which consultations felt uncomfortable.
  • C) Ask for specific feedback on a named area, and check it against your own self-assessment.
  • D) Work on whatever the last lecture happened to cover.

  Reveal answer

  ---

  2. Commit-then-compare — Design your plan

  Goal

  Build a concrete, four-week plan for one skill.

  Task

  Choose one MAAS skill you want to improve. Write a four-week plan: the specific skill, how you will practise it deliberately, who will give you specific feedback, and how you will know it is improving. Then reveal.

  Reveal exemplar and feedback

  ---

  3. Apply to case — Teaching a junior

  Goal

  Use a teaching moment with a junior colleague to reinforce your own skills.

  Task

  You are three years into practice. A medical student shadowing you says after a consultation: “I noticed you asked ‘is there something else?’ twice — at the start and the end. Why do you do that?” Write down your one-minute explanation. Then reveal.

  Reveal exemplar and feedback

  ---

  4. Reflection — Where your development goes next

  Goal

  Name, in your own words, what you will carry forward from this chapter and the course.

  Task

  Take a few minutes with these four prompts. Write them down for yourself—there is no answer key.

  1. Name one feedback conversation (given or received) that you want to do differently in the next month.
  2. Name one person—a peer, a tutor, a future colleague—you would like to have observing you regularly, and one specific thing you would like them to watch for.
  3. When you imagine yourself ten years into practice, what move from this course do you hope is still part of how you consult?
  4. What, honestly, worries you about keeping these skills as your training intensifies? Name it—the naming is the first half of protecting against it.

  Reveal reflection

  End of MAAS-PREP

  You have worked through the whole course—exploring Reasons for Encounter, history-taking, review of systems, presenting solutions, the process skills that hold it all together, the flow of a single consultation, the arc of a patient over time, the contexts that shape every visit, and the development that will carry you forward. That is a lot of small moves, most of them invisible to patients and essential to them at the same time.

  The course ends here. The practice does not. Keep a pocket of these exercises for a slow afternoon or the week before an OSCE. Bring the item vocabulary into your peer feedback sessions. Notice, from time to time, which moves still feel mechanical and which have become yours. And when a patient tells you something they have not told anyone else, notice that too—it is usually the skills in this course, more than the clinical knowledge, that have made the difference.

  Thank you for working through this with us. We hope it serves you well.

  — Crijnen & Kraan

• 9.3Theme 3 — Self-assessment with MAAS-GP-Self

  You will not always have an observer. Learning to judge your own consultations honestly is what keeps you developing once the course and the supervised years are behind you. The catch is that general self-assessment is unreliable—we are poor judges of our own performance in the abstract. It becomes reliable when it is anchored to clear criteria, which is exactly what MAAS-GP-Self provides. This theme practises using it, and reading the gap between how you see yourself and how an observer does.

  For the reasoning, see Chapter 9 of the handbook (§ 5 — Assessment Approaches · § 6 — The MAAS Ecosystem).

  1. Recognition — Why self-assessment needs criteria

  Goal

  Recognise the condition under which self-assessment becomes trustworthy.

  Task

  Self-assessment is famously unreliable—except under one condition. Which is most likely to be accurate?

  • A) Asking yourself “How did I do?” after the consultation.
  • B) A general sense that it “went well.”
  • C) Scoring your own (recorded) consultation against defined, behaviourally-anchored items—MAAS-GP-Self.
  • D) Comparing how you feel today with how you felt last week.

  Reveal answer

  C. Unstructured self-assessment—”how did I do?”, a sense that it “went well”—is unreliable; we cannot judge our own performance well in the abstract. It becomes reliable when anchored to clear, specific criteria, which is what MAAS-GP-Self gives you: the same behavioural items an observer would use, applied to your own consultation on video. The criteria do the work the global impression cannot. (MAAS-GP-Self — criteria make self-assessment reliable)

  ---

  2. Apply to case — The self–observer gap

  Goal

  Read the gap between your self-score and an observer’s score as information.

  Task

  You score a consultation on MAAS-GP-Self; your supervisor scores the same consultation on MAAS-GP. Your scores are markedly higher than theirs. What does the gap most usefully tell you, and what would you do? Then reveal.

  Reveal answer and feedback

  The gap is information, not a verdict. Rating yourself higher than the observer points to a blind spot—a skill you believe you performed, but didn’t, or not to the level you think. The move is to watch the specific items where you diverge, on the video, with the observer: “show me the moment.” A gap the other way—you scored yourself lower—can mean you are too harsh, or that you noticed something the observer missed. Either way, the value is not the number; it is the conversation the discrepancy opens. (MAAS-GP-Self — the gap is informative)

  ---

  3. Apply to case — Self-scoring on video

  Goal

  Turn an uncomfortable re-watch into structured learning.

  Task

  You have a recording of one of your consultations. Rather than watch it vaguely, write down how you would make it a real self-assessment. Then reveal.

  Reveal exemplar and feedback

  Exemplar: choose two or three MAAS items to focus on (not all at once); watch with those items in hand; mark where each was done, missed, or could be stronger; and note one concrete thing to try next time.

  Compare yours. The discipline is what turns a painful re-watch into learning: specific items, evidence from the tape, one next step—the same specificity you would want from any feedback, now turned on yourself. Watching without items just reinforces the discomfort; watching with them builds the skill. (MAAS-GP-Self — structured video review)

  ---

  4. Reflection — Your likely blind spots

  Goal

  Name where your self-view and an observer’s are most likely to diverge.

  Task

  Name two MAAS items you suspect you rate yourself more generously on than an observer would. Write them down—there is no answer key.

  Reveal reflection

  The items you hesitate over are the ones worth recording and checking against an observer first—that is where the self–observer gap, and therefore the learning, is largest. Self-assessment does not replace external feedback; combined with it, it is powerful, and the combination is what builds the habit of seeing yourself clearly. The clinicians who keep improving are not the ones who rate themselves highly—they are the ones who keep checking. (MAAS-GP-Self — combine with external feedback)

• 9.4Theme 4 — Designing your learning plan

  Your development is, in the end, yours to drive. Teachers and programmes help, but they do not run it. This theme practises taking ownership—building a focused plan, keeping yourself sharp by teaching others—and closes with a reflection on where your development goes from here, and a short farewell.

  For the reasoning, see Chapter 9 of the handbook (§ 8 — Building Your Own Development).

  1. Recognition — Taking ownership

  Goal

  Recognise the most reliable way to find your next learning goal.

  Task

  Your training will not always hand you your next goal. What is the most reliable way to find the one skill to work on next?

  • A) Wait for your tutor to tell you at the end-of-term review.
  • B) Guess, from which consultations felt uncomfortable.
  • C) Ask for specific feedback on a named area, and check it against your own self-assessment.
  • D) Work on whatever the last lecture happened to cover.

  Reveal answer

  C. Development you drive beats development you wait for. Asking—“did you notice moments where I missed emotion?”—gets you specific, actionable data; pairing it with self-assessment (the gap from Theme 3) shows you your blind spots. B is unreliable: discomfort and weakness are not the same thing. A and D leave the wheel in someone else’s hands. The owner of your learning is you; everyone else assists. (MAAS — owning your development)

  ---

  2. Commit-then-compare — Design your plan

  Goal

  Build a concrete, four-week plan for one skill.

  Task

  Choose one MAAS skill you want to improve. Write a four-week plan: the specific skill, how you will practise it deliberately, who will give you specific feedback, and how you will know it is improving. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  “Skill: reflecting emotion (B.2). Practice: in every consultation this week, make one explicit reflection before moving on. Feedback: ask a peer to watch two consultations and mark B.2. Track: count the consultations where I reflected at least once, and re-watch one on video at week four.”

  Compare yours with the exemplar. A plan works when it is specific (one named skill, not “communicate better”), deliberate (a focused move, not “try harder”), observed (someone else’s eye), and measurable (you can tell whether it changed). A plan that is all four turns four weeks into visible progress; a plan that is none of them turns into a good intention. (MAAS — deliberate practice; learning plan)

  ---

  3. Apply to case — Teaching a junior

  Goal

  Use a teaching moment with a junior colleague to reinforce your own skills.

  Task

  You are three years into practice. A medical student shadowing you says after a consultation: “I noticed you asked ‘is there something else?’ twice — at the start and the end. Why do you do that?” Write down your one-minute explanation. Then reveal.

  Reveal exemplar and feedback

  Exemplar:

  “Good noticing. It’s the bookend move — items A.2 and A.8. The evidence is striking: about half of patients’ concerns don’t get mentioned unless they’re invited specifically, and the closing question catches what came up during the visit but wasn’t raised. The word matters too — ‘something’ works much better than ‘anything’ because it assumes there’s more to hear. I’ll sometimes forget when I’m tired or rushed, and I always notice the consultation going differently when I do. It’s ten seconds; it changes what the patient feels free to say.”

  Compare yours with the exemplar. Notice what happened as you wrote it: you had to articulate why a move matters, which forces you to understand it in a new way. Teaching juniors is one of the most reliable ways senior clinicians keep their own skills sharp—free, available in almost every consultation room, and useful to the junior too. The move you teach becomes the move you are least likely to drop. (MAAS — teaching while learning)

  ---

  4. Reflection — Where your development goes next

  Goal

  Name, in your own words, what you will carry forward from this chapter and the course.

  Task

  Take a few minutes with these four prompts. Write them down for yourself—there is no answer key.

  1. Name one feedback conversation (given or received) that you want to do differently in the next month.
  2. Name one person—a peer, a tutor, a future colleague—you would like to have observing you regularly, and one specific thing you would like them to watch for.
  3. When you imagine yourself ten years into practice, what move from this course do you hope is still part of how you consult?
  4. What, honestly, worries you about keeping these skills as your training intensifies? Name it—the naming is the first half of protecting against it.

  Reveal reflection

  This exercise has no answer key. What matters is that you can say, in your own voice, what you are carrying forward and what you will need help with.

  The skills in this chapter—receiving feedback without defending, asking for specifics, judging your own consultations honestly—are the ones that turn your next decade of consultations into learning rather than repetition. They are not dramatic skills. They are small, repeated moves: asking someone to watch you, saying “yes, show me the moment,” writing a sentence after a consultation about what you would do differently. Most clinicians who stay sharp across a career do not have a secret technique; they have a small, regular habit of inviting honest observation, and they protect it when everything else pulls at their time. That is the habit this course has been quietly teaching you to build. (MAAS — sustained development)

10End of MAAS-PREP