The Most Common Mistakes Doctors Make in the Opening of Consultations

The First 60 Seconds: How to Nail the Opening of Every Consultation

Why the First 60 Seconds Can Make or Break the Consultation
Every doctor knows that the first minute of a consultation sets the tone for everything that follows. In real practice, patients decide within seconds whether they feel listened to, respected, and safe in your care. In high-stakes exams like the MRCGP SCA, examiners are assessing those same subtle cues: warmth, professionalism, rapport, and efficiency.

Think of the first 60 seconds as the runway for your consultation. If you take off smoothly, the whole flight is easier. If you stumble at the start—awkward greeting, failure to set an agenda, ignoring patient cues—you spend the rest of the consultation trying to recover.

Nailing the opening is not about being scripted or robotic. It’s about mastering a set of habits and principles that work every time, no matter the case or the patient.

The Anatomy of the First 60 Seconds
Let’s break down what happens in that golden first minute. It can be thought of in five key stages:

1. Greeting and Identity – Establishing who you are and confirming who the patient is.
   
   
2. Rapport and Warmth – Non-verbal and verbal cues that make the patient feel at ease.
   
   
3. Setting the Agenda – Inviting the patient to share their reason for attending.
   
   
4. Active Listening Signals – Demonstrating from the start that you are tuned in.
   
   
5. Structure and Flow – Laying the foundation for a clear, safe consultation.
   

Let’s go deeper into each.

Stage One: Greeting and Identity
This is where many IMGs falter—not because they lack knowledge, but because greetings are deeply cultural. In the UK, the ideal opening balances professionalism with warmth.

Pitfalls:

• Overly formal: “Good morning, please state your name and date of birth.”
  
  
• Overly casual: “Hi mate, what’s up?”
  
  
• Missing self-introduction: jumping straight into history-taking.
  

Balanced British Opening:

• “Hello, I’m Dr. [Name]. You must be Mr. Khan? Lovely to meet you. How would you like me to address you today?”
  

Notice the structure: introduction, confirmation, invitation. It is professional, but human.

Stage Two: Rapport and Warmth
Rapport is not a luxury; it is an exam mark. It is also what real patients remember most. In the first seconds, rapport is non-verbal as much as verbal.

Non-verbal strategies:

• Eye contact (but not staring).
  
  
• A slight smile.
  
  
• Open posture, uncrossed arms.
  
  
• Leaning forward slightly to show engagement.
  

Verbal strategies:

• Acknowledging something personal: “I see you’ve brought your daughter—thank you for coming in together.”
  
  
• Empathetic cue: “How are you feeling today?”
  

The patient feels like a person, not a problem.

Stage Three: Setting the Agenda
This is the critical skill that separates pass from fail in the SCA and good from great in real practice. If you don’t establish the agenda early, you risk chasing multiple rabbit holes and missing the patient’s true concern.

Techniques:

• Open invitation: “What brings you in today?”
  
  
• Patient-centered framing: “What would you like us to focus on?”
  
  
• Agenda negotiation (if multiple problems): “I see you’ve got a few things on your mind. Let’s decide together what we can cover today, and we can make a plan for the rest.”
  

This shows respect for the patient’s priorities while keeping control of time.

Stage Four: Active Listening Signals
From the very first response, patients are subconsciously assessing: Are you really listening? In exams, role-players are trained to pick up whether you signal attentiveness.

Strategies:

• Nodding and brief encouragers (“I see,” “Go on”).
  
  
• Echoing key words: “You said this pain has been nagging—tell me more.”
  
  
• Allowing silence rather than rushing to the next question.
  

Active listening in the first minute reassures patients that they won’t be interrupted or dismissed.

Stage Five: Structure and Flow
Before the minute is up, the patient should know:

• Who you are.
  
  
• That you’re approachable.
  
  
• What the consultation is about.
  
  
• That you will listen.
  
  
• That there will be structure.
  

One effective transition phrase is:

• “Thank you for sharing that. Let’s go through things step by step so I understand fully, and then we can make a plan together.”
  

This simple sentence signals collaboration, safety, and flow.

Practical Phrases for the First 60 Seconds
Having a mental toolbox of stock phrases reduces panic and creates consistency. Here are examples IMGs can adapt while keeping authenticity:

• Greeting: “Hello, I’m Dr. Smith. How are you today?”
  
  
• Patient identity: “Can I just confirm, you’re Mrs. Jones?”
  
  
• Rapport opener: “I can see this has been bothering you—thanks for coming in.”
  
  
• Agenda setting: “What’s the most important thing you’d like me to help with today?”
  
  
• Transition phrase: “Okay, let’s go through this carefully.”
  

Common IMG Pitfalls in the First 60 Seconds
1. Diving Straight Into Medical Questions

• Pitfall: “How long have you had the cough?” before even greeting.
  
  
• Correction: Always greet and establish rapport first.
  

2. Over-Formality

• Pitfall: Using rigid language like “State your presenting complaint.”
  
  
• Correction: Use natural, conversational phrasing.
  

3. Ignoring Patient Agenda

• Pitfall: Jumping into your own checklist without asking patient expectations.
  
  
• Correction: Early ICE questions integrate agenda-setting seamlessly.
  

4. Time Mismanagement

• Pitfall: Spending two minutes on small talk.
  
  
• Correction: Warmth is brief but genuine—then move into structure.
  

Role of Empathy in the Opening
The opening is the best time to express empathy, because it establishes tone. Simple acknowledgements of difficulty go a long way.

• “That must be frustrating.”
  
  
• “I can see this has been worrying you.”
  
  
• “Thanks for sharing that—it can’t have been easy.”
  

Empathy early prevents defensiveness later.

The First Minute in Exam Contexts
In the SCA, examiners are marking communication, rapport, and patient-centeredness from the first second. Many candidates panic about “running out of time,” but paradoxically, taking 30 seconds to set up a structured, warm opening saves time later.

What examiners want to see in the first minute:

• Greeting.
  
  
• Identity confirmation.
  
  
• Empathy or rapport.
  
  
• Agenda setting.
  
  
• Smooth transition into history.
  

The Psychology of First Impressions
Research shows humans form impressions within 7 seconds. In consultations, this means tone of voice, posture, and choice of first words carry disproportionate weight. A fumbling start creates anxiety in patients; a calm, confident one creates trust.

This is why rehearsing openings is as important as rehearsing management plans.

Using Non-Verbal Skills to Boost the First Minute
Voice

• Warm, steady, not rushed.
  
  
• Avoid monotone.
  

Eye Contact

• Enough to signal engagement.
  
  
• Avoid staring or looking at the screen first.
  

Body Language

• Sit squarely, not half-turned.
  
  
• Hands visible—not fidgeting with pen.
  

These details, often subconscious, influence examiner scoring and patient trust.

Handling Awkward Starts
Sometimes the first minute doesn’t go as planned. The patient may launch into a long story, seem hostile, or present multiple problems at once.

Strategies:

• If patient launches: “I hear this is important to you—let me just make sure I capture the key points, then we’ll go through them.”
  
  
• If patient hostile: “I can see you’re upset—it’s important we get this right, so let’s go step by step.”
  
  
• If multiple problems: “I want to do justice to your concerns—let’s prioritise today and plan for the rest.”
  

These phrases regain control without shutting patients down.

Practicing the First 60 Seconds
Like any clinical skill, the opening needs rehearsal. Tips:

• Roleplay just the first 60 seconds with colleagues repeatedly.
  
  
• Record yourself—do you sound rushed, flat, or overly formal?
  
  
• Build muscle memory of greeting and agenda setting so it flows under stress.
  
  
• Try varying tones—formal, warm, brisk—and see which feels authentic.
  

Why Authenticity Matters
The danger for IMGs is sounding scripted. Patients (and examiners) pick up on rehearsed lines that lack warmth. The goal is not to memorize, but to internalize principles. Greet, empathize, set agenda, listen. You can do this in your own authentic voice, with your own cultural flavor, as long as it aligns with UK expectations of professionalism and patient-centeredness.

The First 60 Seconds Beyond Exams
These skills are not just for exams—they matter in real GP practice. Patients with chronic conditions, anxiety, or multiple comorbidities often feel rushed or dismissed. A strong first minute—warm, structured, patient-centered—reduces conflict, increases adherence, and improves satisfaction.