Rapport building

Andrew K K Ip 葉傑權

HK Pract 2007;29:1-2

In the context of family medicine, rapport is one very important element for day to day consultations. Establishing rapport is the basic skill to communicate with patients. It is also the foundation to take a good history and to deliver quality health care.

According to Wikipedia, rapport is one of the most important features or characteristics of unconscious human interaction.1 It is being in common in perspectives, being in "sync", being on the same wavelength as the person you are talking to.

Rapport is the foundation of a therapeutic relationship.2 Rapport building requires the participation of the doctor and the patient. Rapport cannot be established if any one of the parties declined to commit himself or herself. Rapport is established with trust. Patients will only release their information to a trustworthy doctor and doctor shall trust the patient's statements. Blaming is almost always destructive to rapport. Labelling the patient as 'malingering', 'difficult' or 'non-compliance' would not be helpful. Often, these actions are damaging to the established trustful relationship.

In one study on teaching of medical communication skills, it was demonstrated that faculty teaching of communication skills varied widely on the issue.3 Only minority within faculty identified opportunities to comment on rapport building. Faculty also appeared to focus the opportunities of rapport building only at the beginning of interview and then overlooked in later part of the consultations. These findings illustrated the difficulties in teaching rapport building. Clinicians often could not identify opportunities to establish rapport during normal consultations.

Rapport is built along with the communication process which begins with the patient interview. Essentially, communication consists of two main components, namely vocalization and non-verbal components.4 Non-verbal component includes appearance, gestures, postures, eye-contact and touch. The doctor should appear and dress like a person, who is neat, tidy and trustworthy. Eye-contact implies that the doctor is attentive and invites the patient to continue to talk. Sitting back at the chair gives a feeling of relaxation and helps the patient to loosen up. Crossing the arms in front of the chest looks like to close the connection of conversation to patient and therefore, should be avoided as far as possible.

Rapport refers to a relationship, connection and being in sympathy.5 It is suggested, you can establish rapport by asking topics which indicate respect and interest. The following are a few examples "You live far away. How long does it take to come here?" "It is cold outside. Do you wear enough?" These questions may be helpful in starting the interview. However, it might not be always feasible to ask unrelated questions in a busy clinic.

Neuro-linguistic programming (NLP) is one of techniques, which is supposed to be beneficial in rapport building. NLP is based on the idea that our mind, body and language all interact together to form our perceptions or 'map' of the world around us and that our perception of it and ourselves can be changed.6 It was co-founded and developed jointly by Richard Bandler and UCSC assistant professor of linguistics John Grinder under the tutelage of noted anthropologist Gregory Bateson, at the University of California.

NLP offers a mirroring approach that one could utilize to establish rapport with patients in one's office.7 Both physical and verbal mirroring techniques could be easily adopted into the daily practice during history taking or patient interviews.

Physical mirroring is to take a posture similar to the patient as if the patient looks into the mirror. If the patient tilts the head to the right, the doctor will tilt the head to the left so that both heads are pointing to the same direction. When the patient leans forward, the doctor shall take a similar forward leaning posture. When patient crosses the left leg over the right, the doctor shall cross the right leg over the left so that doctor is the mirror image of the patient.

Verbal mirroring is approximating the patient's voice tone and repeating the last few words of the sentence and encouraging the patient to say more. It is different from paraphrasing, which edits and summarizes the patient's words. There are excellent examples in the article by Clabby J and O'Connor R.7 Interested readers are recommended to read the original paper.

Personal experience finds that the NLP is a useful technique to establish rapport and to enable an effective communication early in the interview. Patient often elaborates and volunteers information in addition to what the patient supposes to give. NLP can be applied in busy clinics and optimize patient communication. Primary care doctors may consider adopting these techniques to improve rapport building in our daily clinical practice.