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2 01 How to learn this area of practice

Work-based activities

As a specialty trainee, primary care is the ideal place for you to learn about the GP consultation in practice. There will also be excellent opportunities in secondary care settings. Examples of how to make the most of your clinical experience include: 

  • Video analysis of consultations. This can be done using the consultation observation tool (COT)
  • GP trainers can sit in with specialty trainees to give formative feedback. This can be done using the COT
  • Random case analysis of a selection of consultations. This can be done using case-based discussion (CBD)
  • Reflection on secondary care consultations using the clinical evaluation exercise (mini-CEX)
  • Patients’ feedback on consultations using validated satisfaction questionnaires or tools, for example the RCGP patient satisfaction questionnaire (PSQ)
  • Sitting in with GPs and other healthcare professionals in practice to observe different consulting styles
  • Observation of consulting behaviour during outpatient clinics

As a GP trainee you should have opportunities to discuss ethical and other values-related aspects of your practice with colleagues as these arise in your day-to-day work: in addition to contact with patients, their families and the wider community, relevant contexts include such areas as audit and significant event review meetings, and developing practice policies (e.g. on patient consent or on the appropriate use of health service resources). It is particularly helpful if there is ‘protected time’ for reflection and shared learning in which training resources (articles, case studies, etc.) are combined with discussion of real issues arising in your own practice. Presenting cases to your peer groups as part of the more formal training programme will promote reflective practice and can be used to illustrate the diversity of values within a specific professional group.

It is also important for specialty trainees to understand that the practice of medicine has its own culture, values, morals and beliefs that may set doctors apart from patients. During your training you should be supported to gain a better understanding of the diverse nature of the society in which you will work. You should also learn to ask questions and look critically at your assumptions and attitudes about people who are different from yourself, as well as to reflect on these issues and, importantly, on your own feelings. The specialty trainee working in a hospital or in primary care should be training in an environment that embraces differences and similarities in culture, backgrounds and experience. This should be an environment free from racism, sexism and bullying where there are positive role models and processes in place that promote equality and value diversity in the workplace.   

Self-directed learning

Courses or teaching using role-played consultations are tremendously valuable in exploring consultation behaviour in a safe environment, especially those using ‘standardised patients’.

Peer-group meetings are an excellent forum for you to discuss, in confidence, video-taped consultations recorded in your surgery or using commercially available teaching packages. For example, the RCGP’s training DVD ‘Consulting: communication skills for GPs in training’ is an excellent resource for specialty trainees and established GPs who wish to improve their consultation skills.

Competent GPs who wish to develop further expertise in consulting may find the consultation expertise model useful [12]. This model presents a schematic representation of what expert family doctors actually do, which can be used to analyse an individual consultation to produce a ‘fingerprint’ of the level of expertise demonstrated in that consultation. The consultation expertise model was developed to explain the observed differences in behaviour between specialty trainees and experienced GPs during simulated consultations.

Balint groups

The Balint group is a highly developed and tested method of small-group consultation analysis that aims specifically to focus on the emotional content, not just of single consultations but of ongoing doctor–patient relationships. Many doctors who have had the experience of Balint training attest to the lifelong benefits that it can bring in terms of interest in patients’ lives, self-knowledge, job satisfaction and prevention of ‘burn out’. A growing body of research evidence supports the effectiveness of Balint training in many countries [13,14,15,16].

The aims of a Balint group, as recognised by the Balint Society are:

  • To provide a safe environment where group members are able to talk in confidence about the feelings aroused in them by their patients
  • To encourage the doctors to see their patients as human beings with a life and relationships outside the surgery, and a history going back to childhood that has helped to determine what they have become
  • To help doctors explore in detail the emotional content of their interaction with a particular patient: to understand how their behaviour and reactions have been unconsciously affected by the feelings projected by the patient, and resonating with those of the doctor
  • To help learn how to contain a patient’s feelings even when these are uncomfortable and to tolerate feelings such as helplessness and anxiety
  • To help understand how a distressed patient may need to be held and supported in an ongoing therapeutic relationship, in a series of consultations with the same doctor over a period of time

If you have concerns about your own clinical performance – for example perhaps you are returning to work after a period of absence, or you have health problems which may be impacting on your performance – you can self-refer to the National Clinical Assessment Service (NCAS) through their telephone advice numbers on their website. They provide expert advice about the steps you can take and where you can go for help. See the NCAS website.

Learning with other healthcare professionals

The consultation can be used as a focus for your discussion with other health professionals, either by observing a live consultation, using role-play or by watching video-taped consultations. Consultations are a rich learning resource that can trigger multidisciplinary discussion about consulting skills, patient management, ethics, evidence-based practice, clinical guidelines, and many other things.

The emerging integrated care pathways and multi-professional team meetings offer valuable means to learn from the wider team, including social workers and secondary care consultants.

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