At the heart of general practice is the consultation, the means by which general practitioners (GPs) ‘ply their trade’ and deliver best practice care. In its simplest form, the consultation is the sharing of information between patient and doctor, to develop both a common understanding and a plan of management.
Consultation skills are the range of skills that underpin the effective doctor–patient encounter.1 They encompass communication skills, as well as skills such as relationship building, identifying agendas, shared decision making, time management and follow-up. The development of consultation skills is a fundamental element of Australian general practice training.2
Aim
In 2014, we published a paper on consultation skill tips for new GP registrars.3 That paper covered practical, evidence-based tips and suggested model phrases to help registrars new to general practice effectively navigate the consultation.
The present paper describes a range of additional consultation skill tips for GP registrars (Box 1). It also includes additional phrases for registrars to trial as they develop their own vocabulary. As with the original article, we believe this paper will be a practical resource for GP registrars, junior doctors, medical students and supervisors to help undertake an effective and safe general practice consultation.
| Box 1. Practical tips and model phrases for a safe and effective general practice consultation |
Preparing for the consultation
- Organise your desk and room at the start of the day, and between patients
- Complete and close all previous patient records
- Review the appointment book at the start of the session and prepare as able
- Check whether you have seen the patient before (or as a parent of a child)*
- Review the last visit and recent investigations/correspondence*
- Take a break after a difficult or emotional consultation*
Connecting with the patient and building rapport
- Let the patient talk uninterrupted for the first minute*
- Use appropriate expressive touch*
- Avoid being distracted by the computer – take ‘time out’ to look up results, read letters:*
‘Please excuse me while I look up your results’
- Identify and refer to important patient details – preferred name, occupation, life events
- Express empathy overtly:
‘That must be really tough for you’
Identifying the patient’s agenda
- Ask about the patient’s ideas, concerns and expectations (ICE):*
‘What do you think is going on?’
‘What are you particularly worried about?’
‘What were you hoping to get out of the visit today?’
- Look for a hidden agenda:*
‘Is there something else you want to address in the visit today?’
- Actively listen for words related to ICE
- Look for subtle non-verbal signs of discomfort or concern (‘what is not said’)
Gathering data
- Summarise the history back to the patient:
‘Please let me know if I haven’t got the story right, but what I understand is …’
- Explore the meaning of potentially ambiguous terms:
‘Can you please describe what you mean when you say …’
- Use validated assessment tools
- Examine the patient routinely*
- Expose the patient adequately*
- Use checklists for physical examination in specific presentations
Managing uncertainty
- Seek information routinely*
- Ask your supervisor*
- Use Murtagh’s diagnostic framework*
- Use a diagnostic pause:*
‘I’m just going to take a minute to think through the diagnosis’
- Use watchful waiting*
- Order tests judiciously*
- Listen to your gut feelings*
- Safety net*
- Explore ICE in the ambiguous presentation
- Use ‘uncertainty’ flags for help-seeking
Explaining the problem
- Discuss the probable diagnosis and clinical reasoning before management:*
‘After listening to your story and examining you, I think that the most likely diagnosis is …’
- Address the patient’s agenda:*
‘I am aware that you were concerned about something serious …’
- Use diagrams or visual tools
- Use patient information resources to guide explanation
- Assess health literacy
Management planning
- Involve the patient in decision making:*
‘Where do you think we should go from here?’
- Use ‘we’ when discussing management plans*
- Use a management pause:
‘I will just have a quick think before we discuss a plan’
- Give the patient a written management plan
Follow-up and safety netting
- Have a low threshold for getting patients back for review*
- Telephone patients if concerned*
- Safety net patients of concern*
- Safety net receipt of investigations
Managing time
- Identify the ‘list’ of problems early in the visit*
- Prioritise which is the most important issue for both the patient and the doctor*
- Ask patients to return for another visit*
- Signpost time:
‘As we are nearing the end of the visit …’
Telehealth
- Identify the patient
- Ensure privacy and confidentiality
- Use remote examination techniques
- Use enhanced safety netting
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| *Tips covered in the first article. |
Consultation models
Consultation models can provide a useful framework to learn about the importance of a structured, patient-centred and safe consultation. A new framework for the consultation in the Australian context was published in 2022.4 Although our paper does not propose a new model, we believe that the consultation skills tips presented below have applicability to existing models.
Consultation skills
Preparing for the consultation
Adequate preparation is an important but commonly overlooked aspect of the consultation. Preparation incorporates Neighbour’s ‘housekeeping’ step, looking after oneself and preparing mentally for the next patient.5 We encourage registrars to also practise literal housekeeping, ensuring that the consultation room is organised at the start of the day and between patients (ie maintaining an uncluttered desk and clean examination couch). The electronic medical records of any previous patients should be closed. A further housekeeping tip is to routinely review the appointment book at the beginning of the session and consider any specific preparation that might be helpful.
Connecting with the patient and building rapport
Connecting with the patient is a critical consultation skill. We have previously discussed the importance of letting the patient talk uninterrupted and avoiding being distracted by the computer.3
The Kalamazoo consensus statement on the essential elements of communication in medical encounters lists the first consultation task as ‘building the relationship’, by demonstrating ‘care and concern’ through verbal and non-verbal means.6 Registrars can facilitate rapport building by use of a range of well-described communication skills, including eye contact, active listening and open body posture.7
We recommend a few additional strategies for rapport building. First, during introductions, the patient’s preferred name (and pronunciation) should be clarified. For example, elderly patients might prefer being addressed more formally as ‘Mr’ or ‘Mrs’, whereas other patients might prefer an abbreviated version of their name, or a nickname. Once identified, using this name frequently during the consultation can help facilitate familiarity and connection. Similarly, identifying the patient’s occupation, and specifically referring to this as part of management planning, has been described as a useful rapport-building technique.8 A related tip is to make a note of significant life events for the patient (eg a granddaughter’s wedding) and refer to these at a subsequent visit.
Another effective rapport-building strategy we encourage is the overt expression of empathy. Although empathy with a patient’s circumstances can be demonstrated in subtle and non-verbal ways, where appropriate we suggest a more overt expression; for example, ‘That must be really tough for you’. This strategy is the final element of the popular BATHE counselling technique (a simple patient-centred procedure that consists of a series of four specific questions about the patient’s background, affect, troubles, and handling of the current situation, followed by an empathic response).9
Identifying the patient’s agenda
Patient-centred care has been described as the clinician attempting ‘to enter the patient’s world to see illness through the patient’s eyes’.10 We previously discussed the value of actively seeking the patient’s agenda with direct questioning.3 Further to this, we recommend registrars actively listen for, and explore the meaning behind, words relating to the patient’s ideas, concerns and expectations (ICE); for example:
- Ideas: ‘I think …’, ‘I believe …’
- Concerns: ‘I’m scared …’, ‘I’m worried …’
- Expectations: ‘I hope …’, ‘I wish …’
The patient’s agenda might be identified, or at least suggested, as much by ‘what is not said’ as what the patient vocalises. Valuable clues might be picked up from the patient’s demeanour, facial expression or gestures. Similarly, the registrar might observe a subtle change in body language or the tone of a patient’s voice at a particular point of the consultation, potentially opening the door to a hidden agenda.
Gathering data
We have expanded this heading to ‘Gathering data’ in this follow-up paper in order to incorporate the skills of history taking and better describe this early phase of the encounter. Our observation is that a commonly overlooked consultation skill is ‘summarising’: pausing every now and again during history taking to reflect back a summary of what the patient has said.5 Summarising is an effective technique to clarify ambiguities or seek missing information. A related technique is ‘rephrasing’, reporting back what the patient has said in a different form of words to help clarify meaning. We encourage a form of words like ‘Please let me know if I haven’t got the story right, but what I understand is …’.
Effective data gathering data not only comprises history-taking skills and sound reasoning, but also the capacity to ‘unpack’ the meaning of certain terms that might be ambiguous or misleading. For example, words like ‘dizziness’ or ‘anxiety’ might have a very different meaning for the patient and registrar. We suggest registrars use a form of words like ‘Can you please describe what you mean when you say …’ to help clarify understanding.
Another tip for effective history taking is for the registrar to use validated assessment tools for a range of common presentations, such as the International Prostate Symptom Score for lower urinary tract symptoms11 or the Depression, Anxiety and Stress Scale 21 for mental health assessment.12
In our first paper, we flagged the importance of a focused examination with adequate exposure of the patient.3 An additional tip for physical examination is to have a checklist of the core elements of physical examination for specific, and likely unfamiliar, patient encounters (eg six-week baby check, drivers licence medical, age 75+ health assessment).
Managing uncertainty
Our first paper listed a range of strategies for the management of uncertainty, including seeking help, using a diagnostic pause, listening to gut feelings and safety netting.3
We propose an additional couple of tips for new registrars in the domain of managing uncertainty. The first is the strategic use of asking ‘ICE questions’ when faced with an ambiguous presentation. Our experience is that asking such questions can provide greater clarity and allow a more patient-centred management plan when faced with clinical uncertainty.
Another strategy is the use of the so-called ‘uncertainty flags’. This term was coined in a 2020 research paper that described circumstances in which a GP registrar should have a low threshold for calling their supervisor for assistance.13 A list of 10 general scenarios was presented; for example, when considering a referral to the emergency department or when a patient asks for a second opinion.
Explaining the problem
Providing an adequate explanation to the patient, including the probable diagnosis and the underpinning clinical reasoning, is a key consultation skill. This is referred to as ‘the wrap’ in the Roth framework.4 Registrars can use diagrams or other visual tools to assist with explanations; drawing or making a list of dot points is especially useful. Another useful tip is to print a reputable patient information leaflet and talk through the key points with the patient; this can give confidence to the registrar in scaffolding the explanation of a potentially unfamiliar problem.
The capacity of patients to understand health information is highly variable and it is known that low health literacy is common in Australia.14 Although formal assessment of the health literacy of individual patients is impractical, we suggest registrars use more general strategies, such as confirming understanding using the ‘teach-back’ method.15
Management planning
Forming a partnership in management with the patient through the process of shared decision making is a core consultation skill.16 There are a number of other important management skills that the new GP registrar can implement, and the heading for this section has consequently been broadened out to ‘Management planning’.
A concept that has recently emerged in the clinical reasoning literature is the ‘management pause’,17 modelled on the ‘diagnostic pause’. The management pause encourages registrars to ask themselves questions such as:
- Why am I choosing this intervention?
- What are the potential downsides?
- What are the potential alternatives?
- What is the patient’s perspective?
Like the diagnostic pause, this is a simply applied intervention that might improve patient centredness and quality of care. We suggest a phrase such as ‘I will just have a quick think before we discuss a plan’.
Another valuable management planning tip is to write a summary of the management plan for the patient to take home, with a copy included in the medical record. This should include pharmacological and non-pharmacological aspects of management, referral recommendations, time frames and follow-up plans. A brief written plan can reduce misunderstanding and enhance self-management and adherence.18
Follow-up and safety netting
Comprehensive safety-netting is a core element of the safe consultation.19 In keeping with the findings of a literature review on safety netting in primary care,20 we now include an additional tip on safety netting relating to investigations. Registrars need to give patients explicit advice about the purpose of tests, how results can be obtained and especially that ‘no news is not necessarily good news’ when it comes to tests (ie if the patient does not hear anything, they should not assume test results are normal).
Managing time
We have previously highlighted the importance of managing the ‘list’ and asking patients to return for another visit. Registrars can flag the type of appointment booked (short or long) to help manage patient expectations and visit length.3 Signposting that the end of the consultation is approaching is an additional strategy to help manage time; for example, ‘As we are nearing the end of the visit …’.
Telehealth
The COVID-19 pandemic has fundamentally changed the nature of Australian general practice with the rapid and sustained shift to telehealth consultations.21 Telehealth poses a number of challenges compared with the traditional face-to-face consultation and requires the use of specific consultation skills to provide safe and effective care. These skills include identifying the patient, ensuring privacy and confidentiality, the use of remote examination techniques and enhanced safety netting.22 However, generally speaking registrars should have a low threshold for asking patients to attend for a face-to-face visit.
Conclusion
We believe that the practical tips described in this paper will help GP registrars to better navigate the consultation at the commencement of training (and beyond) and support safe, effective patient-centred care.
Key points
- The consultation is the sharing of information between patient and doctor to develop both a common understanding and a plan of management.
- Consultation skills are the range of skills that underpin the effective doctor–patient encounter and are a fundamental element of Australian general practice training.
- Consultation models can provide a useful framework to learn about the importance of a structured, patient-centred and safe consultation.
- Model phrases can be valuable for a registrar to trial as they develop their own vocabulary.
- Practical consultation skill tips can help GP registrars, junior doctors, medical students and supervisors undertake an effective and safe general practice consultation.