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2 01 Educational priorities

The consultation is at the heart of general practice. It is the central setting through which primary care is delivered and where many of the curriculum outcomes are demonstrated. As a general practitioner, if you lack a clear understanding of what the consultation is, and how the successful consultation is achieved, you will fail your patients.

Underpinning the learning outcomes in this module is a commitment to patient-centred medicine. This term is often used so loosely that it can sometimes seem to mean little more than ‘good’ medicine [1, 2]. For the purposes of the curriculum, however, as a patient-centred doctor you should be able to demonstrate an awareness of the following three key areas:

  1. Understanding the wider context of the consultation: this means perceiving that your patient is a person; a belief that the sick patient is not a broken machine; and that ‘health’ and ‘illness’ comprise more than the presence or absence of signs and symptoms. A constant willingness, therefore, to enter your patient’s ‘lifeworld’ [3] and to see issues of health and illness from a patient’s perspective, considering social, educational and cultural differences.
  2. Recognising that patient-centred medicine depends on an understanding of the structure of the consultation – in particular that good consultations are often associated with particular consultation styles and skills [4,5,6,7,8]. However, the expectations and preferences of your patients will vary, so that as a patient-centred doctor you must be able to select from a range of styles and skills.
  3. Being committed to an ethical, reflective attitude that enables you to understand and monitor your practice, and develop it to the benefit of your patients.

Consulting and communication skills are often used interchangeably, but effective communication skills, while essential, are only a subset of the knowledge, skills and attitudes required to consult effectively. Within the consultation your patients rely on your skills as a doctor not only to identify any significant illness, but also more frequently its probable absence. Understanding the epidemiology of illness presenting in general practice requires a normality-orientated approach, as opposed to the disease-orientated approach in secondary care. This approach requires the recognition of ‘red flag’ elements in the patient narrative which may represent a significant illness in its early and undifferentiated stage, where urgent intervention is needed in order to minimise risk. Physical examination and investigations should be appropriate, timely and should follow the best available evidence. As a GP, one of the most effective tools at your disposal is the use of time, watching and waiting when it is safe to do so, and also using the continuity of contact with individual patients and their families. The long-term relationship between you and your patient acts as a repository for mutual trust and understanding, which enables high-quality care.

There are ethnic and cultural differences in the way that illness presents. Health beliefs and preferences have a major impact on patient management and on a patient’s willingness to engage with health services. You must be able to handle the challenge of consultations with patients who have different languages, cultures, beliefs and expectations, and in localities where the management possibilities are significantly different (many are illustrated in the case below). Management plans should be negotiated taking account of and respecting your patient’s values and preferences. As a GP you should understand the make-up of your practice population in order to understand the context of your patients. This includes socio-economic factors, ethnic and religious groupings, housing, and unemployment rates. In the increasingly complex world of modern-day healthcare you may also have to act as an advocate for your patients in helping them make choices concerning their own healthcare.

General practitioners, in common with all health professionals, are expected to act in accordance with the ethical principles set out in professional codes of conduct [9]. These codes set both minimum standards and limits of behaviour beyond which a practitioner must not go. Within this framework health professionals make decisions that require application and interpretation of these codes and guidelines to the circumstances of particular cases or situations. To do this they must be able to identify ethical issues arising in practice, evaluate the moral reasoning for different courses of action, and justify their decisions. As a doctor you must be aware of your own personal attitudes, values, and ethical viewpoints and strive to ensure that these do not have a detrimental impact on your care of a particular patient problem.

Consultations are time-constrained. Longer consultations tend to be associated with better health outcomes, increased patient satisfaction and enablement scores. However, your clinical effectiveness depends on effective consulting skills to ensure that whatever time you have with the patient is used efficiently, rather than consultation length per se. As a doctor you need to navigate the patient through the usual phases of the consultation in the appropriate sequence and at an appropriate pace. For example, if you don’t spend sufficient time discovering the reason for the attendance and your patient’s expectations of the consultation, then your management plan is less likely to be appropriate, and patient safety and satisfaction may be compromised.

International studies have shown that effective and informed primary care by highly trained family doctors delivers care that is more cost-effective and more clinically effective than systems with a lower emphasis on primary care [10]. General practitioners need to make efficient use of available resources for any user of the healthcare system and therefore need to know how to find and apply best scientific knowledge that is relevant to a patient at the time they present in primary care.

Many doctors understand and value the consultation, which is often the ‘implicit curriculum’ that they are able to articulate without ever having read the curriculum statements. Appreciating the relationship between the consultation and the rest of the curriculum may help you to explore, learn, use and value the whole curriculum. The ‘areas of competence’ used in the consultation are transferable to other areas of the curriculum, where they can be used and developed further. For example:

  • Your communication skills and ethical approach to patients are transferable to working with colleagues and in teams
  • ‘Practising holistically’ is transferable to ‘community orientation’, where we move beyond considering the impact of problems on the patient/family unit to consider the community/societal impact and our responses to these
  • Shared decision-making (to some degree) is transferable to the context of distributed leadership in the primary healthcare team
  • ‘Clinical management skills’ are transferable to ‘managing medical complexity’, where they are applied in often more challenging contexts, e.g. dealing with multiple problems simultaneously rather than a single issue.

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