CIP School in the Phils.

A question sheet to encourage written consultation questions

on August 9, 2012
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consultation [kon″sul-ta´shun]

1. a deliberation of two or more health care professionals about diagnosis or treatment in a particular case.
2. the provision of expert advice and counseling by an individual with specialized knowledge, as a statistician consulting with health care team members regarding study design.
3. in the nursing interventions classification, a nursing intervention defined as using expert knowledge to work with those who seek help in problem-solving to enable individuals, families, groups, or agencies to achieve identified goals.
consultation-liaison provision of psychiatric services at the request of another health professional, often for physically ill patients in a nonpsychiatric hospital.
telephone consultation in the nursing interventions classification, a nursing intervention defined as eliciting patient’s concerns, listening, and providing support, information, or teaching in response to the patient’s stated concerns over the telephone.

A question sheet to encourage written consultation questions

  1. 1.   Cliff Cunningham, visiting professor of applied psychology
    1. School of Health, Liverpool John Moores University, 79 Tithebarn Street, Liverpool L2 2ER, UK
  2. 1.   Richard Newton, consultant paediatric neurologist
    1. Royal Manchester Children’s Hospital, Pendlebury, Manchester M27 4HA, UK
  3. Dr R Newton

    Accepted 15 November 1999

The aim of quality improvement reports is to answer the following questions:

  1. What was trying to be accomplished?
  2. What makes a change an improvement?
  3. What was the mechanism for change?
  4. What lessons have been learnt?
  5. What are the next steps?



    Interviews with parents and children attending a hospital paediatric neurology clinic indicated they had difficulties in asking questions during consultations.


    To set up a process to enable parents and children to get the information they wanted.

Background and setting

    Two paediatric neurology clinics in separate hospitals in Greater Manchester, UK with a similar client group run by one consultant.


    Various styles of question sheets were evaluated. The one that was chosen asked patients to write down questions and hand these to the doctor at the beginning of the consultation. Question sheets were given to all patients attending one clinic over a 13 week period.

Strategies for change

    Use of sheets: number of patients taking or refusing a sheet, with reasons for refusal, were recorded. Doctors noted those who handed questions sheets to them

    Satisfaction with sheets: patients completed a short feedback form after the consultation

    Effect on consultations: evaluated through interviews with the doctors.

Effects of change

    In total, 66 (41%) of the 162 patients offered the sheet declined: 14 had already prepared questions; eight being seen for the first time felt they did not know what to ask. Seventeen had used the sheet on a previous visit and did not need it again; 19 gave no reason; the rest said they had no questions. Seventy six (47%) patients produced a sheet in the consultation. Of those using the sheet, 64 (84%) liked it and 61 (80%) found it useful. Fifty two (68%) wished to use it at future consultations. The doctors reported that through questions articulated on the sheets many issues, fears, and misunderstandings emerged which otherwise would not have been identified. Concerns about increasing consultation time and clinical disruption did not materialise. In contrast, doctors reported patients to be taking more initiative and control, particularly on subsequent visits. None of these changes was noted in the comparison clinic.

Lessons learnt

    An attractive, clear question sheet proved a simple but effective intervention in the consultation. Parents felt empowered to take control. The approach may have wider applicability, but implementation requires staff training and support to ensure its continuing use; this ensures medical staff adjust to a new consultation format, and that clinic nurses see the value of the sheets and continue to provide them.


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Patients often are reluctant to take the initiative and ask questions,13 and doctors fail to give patients the opportunity to ask questions.4, 5 Yet more accurate recall of information has been found with patients who ask more questions.6 Patients’ questions help doctors to assess understanding and the need for further information.7

Doctors largely control and usually set the consultation agenda. Many patients do want to participate more in the decisions about their care but have difficulty overcoming “the inherent power structure of medical practice” and “time pressures within the consultation”.8 Studies of pre-consultation sessions with patients have found that this empowers patients to ask more questions911; but this is expensive. Pre-selected question lists are often inappropriate because people with knowledge may implicitly be dissuaded from establishing their own agenda. Providing patients with pre-consultation written information, for example leaflets and question prompt sheets that list potential questions, results in more active participation and increases questioning.1216 Doctors felt more satisfied with the consultation and there was no evidence of increased demands, although there may be some increase in consultation duration.14, 16 Time spent talking by the doctor may be positively associated with satisfaction,9 but the opposite can occur.17 Clearly, quality is more important than quantity and is better achieved when patients can communicate their agenda clearly and when doctors respond appropriately.

The studies report that question asking varies with patient variables (age, sex, and social class), the reason for the consultation (check up, diagnosis, and prognosis), and the context (for example, first visit with new doctor).18

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Two paediatric neurology clinics (A and B) run by one consultant in Greater Manchester, UK looking after children who have long term neurological disability or recurrent paroxysmal disorders such as migraine and epilepsy. Families attending the clinics do so for initial diagnosis, a second opinion, to be given the news of disability, or long term follow up. Each clinic has a training role and two or three specialist registrars (and a senior registrar at the time of the study) are in attendance. Their work is supervised by the consultant in charge (RWN) whose practice is to see all families at the end of the consultation where a trainee has led. There is an active policy of encouraging parents to write down questions and bring them to the next consultation. Half the children have epilepsy, and a specialist epilepsy nurse supports work with these families. An auxiliary nurse also supports the clinics with access to a trained nurse.

Clinic support staff identified through informal discussion that it was common experience that consultations were not providing parents and children with the information they needed. This is not a new problem and is well documented. Parents had often not raised the issue concerning them most. Reasons cited were that they were conscious of time pressure on the doctor, or they thought their question was “silly”. Children often had little knowledge about their condition or treatment plan.

It was decided to develop a question sheet to encourage parents to raise the points that were most worrying to them. This required some staff training. Nursing staff needed to see the potential value as part of a quality improvement programme. Trainee medical staff needed guidance on how to incorporate the sheet effectively into the consultation. In both clinics before the study started there was an active policy to encourage parents to bring their written questions along to the next clinic. It was planned to introduce the question sheet only into clinic A, allowing comparison with the standing policy which continued in clinic B.

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In 1996, as part of a project to define the information needs of children with epilepsy an exploratory project was undertaken to elicit families’ views of medical services. We became aware that users of our service were likely to want and need more information about the relevant condition than we were providing. To explore this assumption CC interviewed, using semi-structured interviews, a convenience sample of 15 parents and children from six clinics. They were asked about things they felt might be improved, if they were receiving relevant information, whether they still had unanswered questions, and in particular if the child’s worries and needs were being addressed. Although there was a high level of satisfaction with the service, many did express difficulties with obtaining relevant information and felt that questions were often unanswered. For example, one child who has attended the clinic for some years asked, “what is epilepsy?” We asked parents if they wrote down their questions before going to consultations and, if so, did they find it useful and if not, why not? Although all felt this approach to getting information “was useful”, 10 had never written down their questions and only two had shown written questions to the doctor. Several felt that doctors would not like to be shown written questions and one parent, referring to a magazine article, expressed the view that if she did the doctor would consider her neurotic. Others indicated they would provide written questions if this were usual practice.

Yet, despite our policy of encouraging parents to bring questions to the next consultation we estimated that less than 15% of patients had done so in the previous six weeks. This led us to develop a question sheet to be given to families on arrival and handed to the doctor at the beginning of the consultation.

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Designing a question sheet

The initial objective was to develop a more effective way to encourage parents and children to bring their queries into the consultation. Thus we did not wish to produce a sheet with lists of potential questions or strategies. Four question sheets were designed that varied in the amount of explanation that was included. These were presented to a convenience sample of 62 people—parents and patients attending the clinic, students, secretaries, and acquaintances—during a two week period. Ten of the sample were healthcare workers; all had been patients at some stage. They were asked what they thought about the idea and which format would most likely encourage people to write down their questions. All said they would probably use the sheet if it were offered when visiting a doctor: “Just being offered the sheet would make me feel they were interested.” Most preferred informal sheets with minimal explanation. Comments from these groups were used to produce the final version (fig1).

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Key measures for improvement


Is the question sheet effective?

We focused on answering two main questions: (1) will parents use the question sheet? And (2) how will it affect the nature of the consultation? We were also keen to find out which parents would not use it and why, to determine any problems with implementation, and to find out how doctors would feel about parents using it. Our interest was whether doctors would allow parents to be more in control, using the question sheet as a prompt, whether the sheet would complement rather than hamper consultation dynamics, and whether the consultation would be prolonged.


The question sheets were used in one clinic (A) and data about the use of question sheets were collected from 13 consecutive weekly clinics. At the other clinic (B) during the same 13 weeks the consultant (RWN) noted the number of patients who arrived with questions as part of the usual policy.

Nurses in intervention clinic A explained to parents that they were “trying out a new idea to help improve the service” and offered each a question sheet. The number given out and reasons for refusal to take a question sheet were noted but in an unstructured way. Parents were asked to hand the sheet to the doctor at the beginning of the consultation. At the end of the consultation, doctors in clinic A asked if they could place the sheets in the patient’s notes for future reference. Parents who took a sheet were also given an anonymous feedback slip and asked to complete this and post it in a clearly labelled box in the waiting area. The consultant in clinic A had informal discussions with the three other doctors (one senior registrar and two registrars working in this clinic at this time). Notes from these discussions were used to structure an interview with the doctors.

A total of 182 children with one or both parents (in two cases, another close relative) attended the 13 clinics (fig 2). In total, 162 (89%) were offered the question sheet. Thirteen of the 20 parents not offered the sheet went into the consultation before being offered a sheet. The nursing staff did not feel it appropriate to offer a sheet to seven parents—of these seven, five did not speak English.



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