Calgary-Cambridge Guide to the Medical Interview - Closing the Session

Original Editor - Carin Hunter based on the course by Marissa Fourie

Top Contributors - Merinda Rodseth, Tarina van der Stockt and Kim Jackson

Introduction[edit | edit source]

The importance of communication in obtaining good health outcomes is well-known.[1] Communication is a teachable skill that is incorporated in the training of medical professionals at tertiary institutions worldwide. The teaching of communication skills is often based on models of communication, the products of extensive research, providing frameworks for gaining clinical data, building rapport and deciding on clinical management[2] . Kurtz and Silverman[3] introduced the Calgary-Cambridge Referenced Observation Guides, which they further refined in the early 2000s.  These guidelines, which presents the medical interview in five steps, are the result of the collaboration between two very experienced teachers in clinical communication. The guide was originally intended for use in clinical education at tertiary institutes.  The model has since been adapted and used in various health disciplines and serves as a blueprint for many educational institutions in the teaching of education to aspirant health care professionals[4].

Figure 1: Layout of the Calgary Cambridge Model

Challenges experienced in the learning of communication include the integration of communication skills with other clinical skills, and the effective carryover of theoretically taught communication skills into real-life scenarios. According to Kurtz et al[4], these hardships are experienced because students struggle to combine the focus on interview content (i.e. information gained) with the process of communication during the interview (for example, non-verbal behaviour). The Calgary-Cambridge model teaches communication focusing on both interview content and process simultaneously, thereby integrating the traditional clinical method of history taking with effective communication skills. Patient-centred medicine has been incorporated in both content and process[4].

Figure 2: Layout of the Calgary Cambridge Model, with objectives

The Calgary-Cambridge model is presented in three diagrams, which aids to enhance communication skills training visually and conceptually. The first diagram (Figure 1) summarises the medical interview as a sequential five-step process: initiation of the session; gathering information; physical examination; explanation and planning; and closing the session. In the traditional medical assessment, the subjective and objective examinations were considered two different entities. In the Calgary-Cambridge guide, they are integrated, with the inclusion of “physical examination” into the model.  Hereby, the interdependence of information gathering from the physical assessment and verbal communication in the natural flow of a true-life medical assessment is illustrated. Provision of structure and relationship building are two steps that continue throughout the entire interview and that develops increasingly as the interview progresses. Figure 2 provides more detailed and achievable, evidence-based objectives in each of the steps in the medical interview. The last diagram (Figure 3) shows the interrelationship between content and process, using the example of the gathering of information[4].

Figure 3: Relationship between content and process

The Calgary-Cambridge model provides a practical, integrated method of teaching both the process of communication, as well as the effective gaining of content information[5]. It incorporates the importance of patient-centred medicine including the building of a relationship and shared decision making[6]. The model has been the base of many medical interviews and continues to provide guidance to clinicians in all fields of medicine. Watch this video if you want to learn more about the Calgary Cambridge Guide to the Medical Interview:

[7]

Closing the Session in the Calgary-Cambridge Model[edit | edit source]

Closing refers to the final phase of the medical interview, in which both clinician and patient shift their perspective from the present to the future, consolidate and finalise plans for further management, and part ways.[8] Closing is often disregarded as an important part of the medical interview, and research indicates that a proper closing dialogue may be omitted altogether in many clinical scenarios.[9] Closing provides the clinician with a final opportunity to ensure proper comprehension and commitment from the patient. It also plays a significant role in patient satisfaction, the likeliness of coherence to clinician instructions and as a result, the outcome of treatment. [8][9]

Although this last phase of the interview is often perceived as a simple conclusion and termination of the session, it entails a complex interaction between the clinician and the patient. During closing, the clinician should summarise the outcomes of the visit, clarify the plan of care which was formulated during shared decision making, check for patient understanding and unaddressed concerns and establish plans for the interim, all while demonstrating care and compassion with the patient.[8][9]

Closing is divided into two parts, namely forward planning and ensuring an appropriate point of closure.[10] Forward planning consists of contracting with the patient regarding the next steps of treatment, as well as safety netting. When ensuring the appropriate point of closure, a brief clarification and summary are followed by a final check whether the patient is comfortable, agrees and commits to the plan of action (Box 1). Although the Calgary-Cambridge model gives a theoretical layout of the different steps that need to be reached during the closing, they often do not occur stepwise, nor are they exclusive or independent from each other.  Practically, the closing of the session may comprise a short dialogue with only a couple of sentences, in which all the steps described in the model are included.

Box 1: Closing the session

Forward Planning: Contracting and Safety Netting[edit | edit source]

1. Contracting with patients[edit | edit source]

Contracting involves the consent and cooperation of patients for continuing with the proposed management plan. Contracting provides the opportunity to summarise, consolidate, agree and move on to the final stages of closure. Two methods of contracting will be discussed:

  1. The Arrangement sequence
  2. The Final concern sequence

In these two sequences, aspects of clarification/summary and final check are also included.

The Arrangement sequence[edit | edit source]

The arrangement sequence essentially consists of four steps:

  1. Clinician proposal
  2. Patient acceptance/non-acceptance
  3. Clinician requesting confirmation
  4. Patient providing confirmation.

In the case of non-acceptance, a stage of negotiation is introduced until a mutual agreement is reached.[11] However, if proper shared decision making has taken place earlier in the interview, non-acceptance is usually not a pertinent refusal, but rather a statement to ensure that everything is mutually understood.

An example of the arrangement sequence with acceptance from the patient is illustrated in Box 2. The same scenario is illustrated in Box 3, but with an example of non-acceptance.

Clinician providing proposal: “Okay, so as discussed, your thumb should recover well in the next couple of days, providing that you keep it in the splint for optimal protection and to minimise movement. You can also take some medication as prescribed by the GP.”

Patient accepting proposal: “Sounds great.”

Clinician requesting confirmation: “Good, so you will be okay with only taking it off when you want to get your hands wet, and to minimise any use of the thumb for the next week?”

Patient providing confirmation: “Yes, of course.”

Box 2: Arrangement sequence with the patient accepting the proposal

Clinician providing proposal: “Okay, so as discussed, the worst of the acute inflammation in the thumb joint should wear down in the next couple of days, providing that you keep it in the splint all the time for optimal protection and to minimise movement. You can also take some medication as prescribed by the GP.”

Patient not accepting proposal: “Uhm… I’m just a little concerned about bathing my baby... Hubby should be happy to help more with baby duties, but I am afraid he won’t do the bathing part. Will I be able to at least do that?”

Clinician negotiating and investigating problem: “That is totally understandable. It shouldn’t delay the healing process if you take off the splint while bathing the baby, but then you may need to be more careful not to overstrain it." (The clinician takes some time to explain and demonstrate the appropriate technique to the patient.)

Clinician requesting confirmation: “Good, so do you feel comfortable with that? Will you be okay with only taking it off when you want to get your hands wet, and to minimise any use of the thumb for the next week?”

Patient providing confirmation: “Yes, the technique you showed me will work perfectly. I am happy to keep it in the splint for the rest.”

Box 3: Arrangement sequence with patient not accepting proposal

Final concern sequence[edit | edit source]

In the final concern sequence, the clinician provides a summary of what has been decided upon, after which the patient is asked to confirm whether he/she understands the proposed management plan. Any uncertainties should then be mentioned and addressed. The clinician will typically pose a question such as “Do you have any questions?” or “Anything else?”. The patient can either answer “yes” or “no”. Where a patient confirms understanding and has no more questions (i.e. a no-answer), the clinician can move onto the final stages of closing. Where any uncertainties or questions arise (i.e. a yes-answer), either a new concern or a follow-up on an existing concern, is raised. The clinician should then first address the concern, or defer the concern to a follow-up session. Hereafter, the sequence should be restarted. This process should continue until there is no more uncertainty from the patient, and the interview can shift to final closing.[11]

An example of the final concern sequence where no more questions are asked is illustrated in Box 4. Box 5 provides an example of the same scenario as Box 4, but where patient uncertainty is expressed and addressed.

Clinician summarising: "Okay, so we have agreed that your son will continue with the exercises that we have done today and which we have written down for you. As mentioned, he should start weaning from his crutches and take full weight on the foot now. He can still use one crutch when he is going to be on his feet for a long time during the day, or when he really becomes tired. But for home time, try to motivate him to not use the crutch at all and step on his foot with confidence."

Clinician asking yes/no question: "Do you have any questions?"

Patient (caretaker) answering: "No questions, thank you."

The interview then shifts to the final closing.

Box 4: Final concern sequence with a no-answer

Clinician summarising: "Okay, so we have agreed that your son will continue with the exercises that we have done today and which we have written down for you. As mentioned, he should start weaning from his crutches and take full weight on the foot now. He can still use one crutch when he is going to be on his feet for a long time during the day, or when he really becomes tired. But for home time, try to motivate him to not use the crutch at all and step on his foot with confidence."

Clinician asking yes/no question: "Do you have any questions?"

Patient (caretaker) answering: "Yes, there is one thing I am somewhat concerned about. When he gets up in the morning, the ankle really seems quite stiff and uncomfortable, and he is reluctant to stand on it. Would you suggest he should then walk with the crutch, or without it?"

Clinician resolving the issue and asking confirmation: "Very valid question!" (Goes about suggesting warm-up exercises prior to walking and then re-evaluating.) "Does that make sense?"

Patient confirming: "Makes perfect sense, we will try that."

Clinician asking yes/no question: "Great. Are there any other questions?"

Patient answering: "No, everything is clear, thank you."

The interview then shifts to the final closing.

Box 5: Final concern sequence with a yes-answer

2. Safety netting[edit | edit source]

Safety netting is the provision of information and organising of any condition-related matters that may arise following the current session and preceding the follow-up. The aim of safety netting is to help address uncertainty regarding the diagnosis and management of the presenting condition, thereby empowering the patient with knowledge and a contingency plan to help manage their pathology. The clinician will typically summarise his/her findings and/or diagnosis, coach the patient to recognise any relevant adverse symptoms that may develop after the consultation, and provide the patient with a plan and detail of who to contact in the case of unexpected developments. Safety netting does not only supply the patient with the capability to self-manage but also protects the clinician from potential non-disclosure accusation. For this reason, it is recommended to properly document the specific information provided to the patient during safety netting[12]

Safety netting comprises several aspects, including communication of uncertainty, advice on worrying symptoms and red flags, the expected time course of illness, how and when to seek further medical care, arranging a planned follow-up and practical implications of primary care investigations. A summary of these aspects is provided in Table 1.

Aspect addressed Recommendations
1. Communication of uncertainty Any uncertainty regarding the diagnosis should be communicated to the patient so that he/she has the option of a re-consultation. Uncertainty regarding the aetiology should also be disclosed to reduce the risk of false reassurance.
2. Advice on worrying symptoms/red flags Patient should know which pathology-specific red flags or worrying symptoms to look out for and know with how much urgency they should react if such symptoms present
3. Expected time course of illness Symptoms that extend for longer time periods than expected for the proposed diagnosis may warrant further investigation; patients should thus be empowered with knowledge on the normal time course of the disease/recovery
4. Seeking further medical care When red flags or worrying symptoms occur, the patient should know where to seek further help. Information such as contact details and specific processes may be communicated in advance in case they are needed.
5. Arranging planned follow-up When a follow-up is indicated, rather offer to make an appointment for them than requesting them to do it on their own accord.
6. Primary care investigation management In the case of investigations such as X-rays or laboratory tests, patients should understand the role of the investigation, how it is performed and how and when the results will be communicated to them.

Table 1: Aspects of safety netting[12] (adapted)

Ensuring Appropriate Point of Closure[edit | edit source]

Clarification, Summary and Final Check[edit | edit source]

The final stage of the closing consists of a brief summary, finalising plans and saying farewells.[8] The methods of contracting described in this document already involves a degree of clarification, summary and checking. Therefore, if these were performed comprehensively, only a brief encounter is necessary to conclude and ensure that no uncertainty exists. The final part of the medical encounter is often more light-hearted, with some humour and social interaction between clinician and patient. This is a good opportunity for the clinician to demonstrate a concerning and caring attitude and further strengthen rapport and relationship. Conversation during the final moments of the interview should also be conducive for encouragement and reassurance, with the aim of leaving the patient feeling heard, understood, prioritised and well attended to.[13]

Doorknob Concerns[edit | edit source]

Doorknob concerns are demands or consultations by patients that occur at the end of the medical visit, which was not anticipated nor planned for. These additional demands sometimes stem from answers to the yes/no question raised by the clinician at the end of the final concern sequence, or they occur spontaneously just prior to or during the farewells. They are often preceded by a reflexive silence from the patient, and may start with words/phrases such as “…well”, “…uhm”, “…Oh!...”, “…one more thing”, “…and…”, and “…since I’m here…”[14]

There are several reasons why patients wait until the end of the session before mentioning additional concerns. Many times, patients are embarrassed about the condition, especially in the case of a typically stigmatised topic, and only feel comfortable sharing it after some form of rapport has been established with the clinician. Patients with long and complex medical histories often have more than one co-morbidity that also needs attention, and they often only raise a second concern once the initial complaint has been addressed.  For some patients, there was simply not enough time during the gathering of information to disclose their additional issue as well. The common factor is usually either poor preparation and communication by the patient or poor guidance and interview skills by the clinician, or a combination of the above.[14][15]

Doorknob concerns are a common occurrence with between 15% and 40% incidence in medical visits. This phenomenon is a source of frustration to most health care practitioners. It interferes with time management and work routine and increases the pressure on the clinician, which often leads to decreased quality of care and medical errors.[14] However, important information is often disclosed in these short time periods and clinicians should take care to not neglect potentially medically significant issues due to time pressure. If necessary, referral to a colleague or arranging a follow-up appointment to address the new concern should be done.[16]

Clinicians can reduce the incidence of doorknob concerns by adjusting and refining medical interview skills and organisation. Firstly, clinicians should ensure that enough room and opportunity is provided for questions and concerns early in the appointment. It is recommended to, at the start of the session, make a list of things that the patient wishes to address. Negotiation of agenda and timing is also important early in the session. During the interview, clinicians should listen attentively to the content of the patient’s account and be sensitive to non-verbal cues. By attentive listening, the clinician may be able to pick up underlying concerns in advance and address them accordingly. Lastly, it is recommended to negotiate for the booking of a follow-up appointment if possible, to be able to address the new issue more comprehensively.[15]

Conclusion[edit | edit source]

The end of the interview is a significant part of the encounter which should not be underrated. Proper closing of the session provides comfort, confirmation and confidence to the patient, empowering him/her with knowledge of further management of the presenting condition. The process of contracting both ensures that the patient commits and understands, and protects the practitioner from non-disclosure. The closing of the interview is in essence the glue that joins the entire medical interview to the rest of the management plan, and if performed well, serves as an excellent base for further management.

References[edit | edit source]

  1. Hiller A, Delany C. Communication in physiotherapy: Challenging established theoretical approaches. Manipulating Practices: A Critical Physiotherapy Reader. 2018:308-33.
  2. Modi, J.N., Anshu, Chhatwal, J., Gupta, P., Singh, T., Teaching and assessing communication skills in medical undergraduate training. Indian Pediatr. 2016 53, 497–504
  3. Kurtz, S.M., Silverman, J.D.. The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Med. Educ. 1996 30, 83–89.
  4. 4.0 4.1 4.2 4.3 Kurtz, S., Silverman, J., Benson, J., Draper, J. Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary–Cambridge Guides. Acad. Med. 2003 78, 802–809.
  5. Ammentorp J, Bigi S, Silverman J, Sator M, Gillen P, Ryan W, Rosenbaum M, Chiswell M, Doherty E, Martin P. Upscaling communication skills training–lessons learned from international initiatives. Patient Education and Counseling. 2020 Aug 28.
  6. Main, C.J., Buchbinder, R., Porcheret, M., Foster, N. Addressing patient beliefs and expectations in the consultation. Best Pract. Res. Clin. Rheumatol. 2010 24, 219–225.
  7. Dr Alex. 2018. Introduction to the Calgary Cambridge Guide to the Medical Interview. Available from: https://www.youtube.com/watch?v=zjAqbWvnFB0
  8. 8.0 8.1 8.2 8.3 White JC, Rosson C, Christensen J, Hart R, Levinson W. Wrapping things up: a qualitative analysis of the closing moments of the medical visit. Patient education and counseling. 1997 Feb 1;30(2):155-65.
  9. 9.0 9.1 9.2 Manalastas G, Noble LM, Viney R, Griffin AE. What does the structure of a medical consultation look like? A new method for visualising doctor-patient communication. Patient Education and Counseling. 2020 Nov 24.
  10. Herqutanto H. Modification of Calgary-Cambridge Observation Guide, a more simplified and practical communication guide for daily consultation practice.
  11. 11.0 11.1 Robinson JD. Closing medical encounters: two physician practices and their implications for the expression of patients’ unstated concerns. Social science & medicine. 2001 Sep 1;53(5):639-56.
  12. 12.0 12.1 Jones D, Dunn L, Watt I, Macleod U. Safety netting for primary care: evidence from a literature review. British Journal of General Practice. 2019 Jan 1;69(678):e70-9.
  13. White J, Levinson W, Roter D. Oh, by the way…. Journal of general internal medicine. 1994 Jan 1;9(1):24-8.
  14. 14.0 14.1 14.2 Turabian JL. By The Way…. Phenomenon: A Qualitative Study of the Additional Demands in Closing Moments of Medical Interview in Family Medicine. J Gen Pract. 2017;5(342):2.
  15. 15.0 15.1 Kowalski CP, McQuillan DB, Chawla N, Lyles C, Altschuler A, Uratsu CS, Bayliss EA, Heisler M, Grant RW. ‘The hand on the doorknob’: visit agenda setting by complex patients and their primary care physicians. The Journal of the American Board of Family Medicine. 2018 Jan 1;31(1):29-37.
  16. Kaufman G. Patient assessment: effective consultation and history taking. Nursing Standard. 2008 Oct 1;23(4).