Too many clinics take far too long. Often this happens because of things that clinicians don’t control. The clinic might be overloaded, the patients might need more time than usual that day, or the internet goes down and everything grinds to a halt.
When I was training though, I was often struck by how often I'd sit in with doctors in all specialties whose clinics always, reliably and relentlessly overran by hours. I was also struck by a lack of willingness to even see this as a problem, much less do anything about it. Those who overran knew they were leaving late. Their colleagues (especially the weary receptionists) knew this was a pattern. And yet, no-one thought to try to improve things.
Perhaps this is because patients expect to wait when they see a doctor or nurse in clinic. A slow-running clinic is tolerated, even expected. “They’re running late because they’re seeing other people,” goes the story – the assumption being that when you the patient finally stagger over the finish line and into the consultation room, you too will bask in the same warm glow of care and competence.
Maybe so. But it’s not a great start. Waiting twenty, fifty, ninety minutes past your appointment time, with little indication of how long before you can get on with the rest of your day, is stressful to say the least. You’re more likely to forget what you were going to ask. Your mind will be on getting home, in the dark.
If you’re a clinician and a slow-running clinic is genuinely outside your control, you can only apologise. If there’s anything you can do to make sure the delay isn’t down to you though, you should.
The key to consultation management
We get taught when we’re training about exploring the patient’s agenda, about open and closed questions, about active listening. All are great. What we don’t get taught about (at least I didn’t) is the absolute importance of building rapport.
Rapport is the oil that lets your clinic’s machine run smoothly. With good rapport, you get fewer complaints. Patients feel you’ve listened to them more, because you have. Your consultations are less stressful, both for you and the patient, meaning you have more energy at the end of the day to make sure you can be your best clinical self for every person you see.
It’s right that you should explore the patient’s agenda. Building rapport should be top of your agenda, for every appointment. Once you’ve done this, something clicks. The mood shifts, body language opens up. You and the patient start to understand each other, start to feel as though you’re on the same page, and start to make progress in getting to a conclusion and a plan.
Many people – even clinicians – don’t really know what occupational health is, what it does, and what’s going to happen in the appointment. Some patients ask to see OH themselves, and expect a positive experience. Some patients think you’re there to get them the sack, and expect quite the opposite. For some people, you are the enemy and this can be quite an intimidating prospect if you don’t know how OH works. This is not conducive to building rapport.
Building rapport step by step
As such, after introductions the first step is to ask what the person seeing you understands about the reasons for the consultation. It’s a targeted question, and gives them an opportunity to talk. If they are upset about being there in the first place, you’re likely to hear about it, which lets you calibrate how you respond.
Second, explain what you’re there to do. You should have a script that works for you, that you pretty much rattle off most of the time. Some people object to the concept of a script, preferring to mix things up and get creative. These are often people who spend a long time in clinics, while others are doing their job effectively. We use scripts for learning to examine the heart, chest and anything else – the same applies to managing a consultation.
Your introduction script is where you explain that the notes you’re writing are confidential and aren’t seen by the patient’s employer. That you will go through the referral form with them so there are no surprises. That you’ll be writing a report and that you’ll explain what’s in it – plus the patient can see the report before it’s sent if they wish. That you are there to discuss health in relation to work, and that you’re there to provide independent health advice, and that you are there to give a balanced opinion, not to reveal confidential information to the person’s manager.
This, admittedly, is more of a spiel than most clinicians in most specialties have to give. It’s why you must ask first what the patient understands about the appointment, so the first couple of minutes don’t feel like a lecture.
Then the third step – going over the referral with the employee. This lets you outline the questions the manager asked and sets your agenda for the consultation. You may have heard some of the employee’s agenda when they told you what they understood about their appointment with you – now you can explore that further.
The referral is your opportunity to talk about what happens at the end of the appointment – namely, the recommendations you’ll make based on the referral. You can’t talk about what those recommendations actually are yet – that’s what the rest of the conversation is about – but highlighting what you’re working towards gives you and the employee a clear idea of what is to be expected.
This isn’t a guaranteed slam-dunk method for getting perfect rapport in every consultation – everyone’s human after all. But it forms the basis of a conversation in which cards are on the table and the rules of the encounter are known to everyone present. It shows the person that you don’t have a hidden agenda, that you’ll deal with them in an honest and transparent way, and that even though you’re not there to treat them, you are a clinician and can be trusted.
To summarise, there are three steps:
Ask what the employee understands about the reasons for the referral
Explain your role and what you’re there to do
Go through the referral and set a framework for the plan you’ll make
This can take ten minutes, which seems a lot. What it is though is an investment in letting a consultation run as well as it can. Information is exchanged so much more easily. You get to the crux of problems. You’re better able to gently interrupt, because you can divert the conversation back to the plan you’ve already laid out rather than just appearing impatient.
Being a more effective occupational health clinician
Making clinics run more efficiently isn’t about clinicians getting home earlier – because most occupational health appointments are pretty long, you’re unlikely to have queues of people in your waiting room you can speed through anyway. Plus, you can have a clinic that’s running perfectly to time and find the last person you see needs longer than expected. So why bother?
We are privileged in occupational health to have in-depth conversations about people’s health and how it impacts them, not only in their work but in their lives. Spending half an hour before you even achieve a basic level of rapport means you have far less time for a ‘real’ conversation that’s based on trust. With no rapport you can't understand someone’s circumstances and you can’t do a good job as an occupational clinician.
Rapport means you take less time to conclude the main part of the conversation. This affords you another unique opportunity – health promotion. Rarely will a patient get to spend as long with a clinician who has a holistic understanding of their function and health, as they do with you. The advice you give about smoking, about weight loss, about reducing cholesterol, about getting vaccinated, can be invaluable for the individual and the organisation they work for. It is one of the many ways we can have a big positive impact on people and engage with them in a ways others may not have a chance to.
Making clinics run faster isn’t about cutting corners or rushing patients to answer your questions. It’s about giving people time to speak, and reassuring them the rules of an interaction they may not be familiar with. A clinician who runs a tight ship in their clinic approaches cases with more confidence. They know that some cases take a long time, and some take less. But in being efficient they can also free up time to really get to understand people, to promote health and to ensure that employees and employers get the greatest possible value from each occupational health appointment.