Consulting in general practice

• Effective communication with your patient and their advocates, including carers, is essential for good care.
• As a general practitioner you must show a commitment to person-centred medicine, displaying non-judgmental attitudes and a holistic ethos.
• Developing plans for care and support with the patient involves a collaborative approach, including agreeing shared goals and considering the patient’s unique values and preferences alongside the best available evidence, as well as applying relevant ethical and legal principles.
• You must manage complexity, uncertainty and continuity of care within the time-restricted setting of a consultation.
• Technology is facilitating new ways of consulting in general practice, for which the same consultation principles hold true, whether using telephone, video or even email or text messaging. Fundamental information governance principles and communication skills still apply with these new methods.

The consultation between doctor and patient is at the heart of general practice. It is the central setting through which primary care is delivered and from which many of the curriculum outcomes are derived. The skills used in the consultation are transferable to other areas of professional practice. For example, your communication skills and approaches with patients are transferable to how you work with colleagues, in leadership and in teaching.

Having highly developed communication skills is pivotal to all aspects of high-quality patient care.

‘Consultation skills’ and ‘communication skills’ are not interchangeable terms; both are subsets within the interpersonal skills, knowledge and attitudes required to consult effectively.

The following three areas have a strong influence on person-centred consulting:

1. Attitudes, feelings and biases

• Subjective feelings, values and preferences of both patients and doctors can strongly influence the consultation. These can bring benefits and risks to the consultation. For example, while they can help you to establish rapport, they can also impact on shared decision-making through conscious and unconscious biases. This is particularly important in areas such as sexuality, sex and gender, age, race, culture, religion, class and educational attainment.
• Some patients will attend the same GP repeatedly during the course of their lives: this longitudinal relationship can influence attitudes, feelings, biases and processes within consultations for both patients and doctors.
• Patients’ views and perspectives may change during the course of their lives and even during the course of an illness.
• Health beliefs, preferences and ethnic and cultural differences have an impact on how patients present in primary care and engage with health services, and approaches to management.
• Adopting a curious and open-minded attitude can offer useful insights into patients’ perspectives.
• Patients make decisions about their health based on both the information they have and their individual preferences, beliefs, and values, which may not align with yours. Accepting and responding to this can improve the patient’s experience and their commitment to agreed care plans.
• Patients sometimes prefer to delegate their autonomy to you as their GP, rather than take responsibility themselves, particularly at times of illness or distress. Being willing to take on this responsibility, when appropriate, is an element of patient-centred care. However, it is important to support patients in maximising their capacity for decision-making, as well as encouraging self-care, in a non-judgmental manner.

2. The consultation process

• A working understanding of a range of consultation models can offer useful insights into the processes and tasks that are central to effective consultations.
• Discovering the reason for the patient’s attendance (their agenda) may be important (such as a specific worry, or anticipated outcome) to help you properly address their concerns and improve satisfaction.
• Patient-centred consulting involves being attentive to what people are communicating (both verbally and non-verbally).
• It is important to be able to monitor the consultation process in real time, and to be able to adapt appropriately, for example, noticing when a consultation is not going as well as hoped and taking appropriate steps to address this.
• Consultations are usually time-constrained. Although longer consultations have been linked to better health outcomes, increased patient satisfaction and enablement scores, balanced against this are the competing demands of appointment capacity, high demand for services and limited access to GPs.
• Constructive feedback on your consultation (both from patients and colleagues), with reference to consultation skills and communication models, can help to improve your consulting skills.

3. The wider context of the consultation

• Consultations, along with episodes of illness, rarely impact on the patient alone.
• It is important to consider the relationship between the interests of patients and the interests of their carers, relatives and friends, keeping in mind the patient’s rights to autonomy and confidentiality.
• It is important to consider and support people undertaking a caring role, both those who are caring for your patient and patients who have a caring role themselves.
• Consultations that work effectively from a patient’s perspective require the doctor to understand that ‘health’ and ‘illness’ comprise more than the presence or absence of the signs and symptoms of disease. You should consider the physical, psychological, socio-economic, educational, cultural and community dimensions of health.
• It is important to understand the boundaries between professionals and other services with regard to clinical responsibility and confidentiality, particularly when working in teams and in care pathways that span organisations.
• Each consultation provides a window to the local community, building a picture of the demography and diversity of your practice population, as well as unmet health needs and gaps in service provision. When combined with data from the wider population, this can inform the development of appropriate services for the community as a whole.
• It is important to address the needs of patients who are less able to access care for whatever reason, for example through lack of access to the internet or confidence with digital technologies, language or cultural differences, or disability.
• Physical, psychological, socio-economic, educational, cultural and community dimensions of health are present in every consultation. Recognising this is a skill that requires thinking beyond the bounds of your own context and into the world of the patient.

Work-based learning

As a GP registrar, primary care is the ideal place for you to learn about the GP consultation in practice. There will also be excellent opportunities in settings outside primary care. 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 sitting in with GP registrars to give formative feedback; this can be done using the Care Assessment Tool (CAT)
• random case analysis of a selection of consultations; this can be done in a Case-based Discussion (CbD)
• reflection on secondary care consultations using the Mini Clinical Evaluation Exercise (MiniCEX)
• patient 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 practice during outpatient clinics
• using the telephone and other digital communication tools to consult in the practice as well as in out-of-hours settings, initially under close supervision and later independently.

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 – for example during contact with patients, their families and the wider community, and in relevant other contexts such as audit, significant event review meetings and developing practice policies (for example on patient consent). It is particularly helpful if there is ‘protected time’ for reflection and shared learning. Presenting cases to your peer groups as part of the 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 GP registrars 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 seek 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 learn to reflect on these issues and, importantly, on your own feelings. The GP registrar working in a hospital or in primary care should be training in an environment that embraces differences as well as similarities in culture, social class and experience. This should be an environment free from racism, sexism, ageism or other bullying, where there are positive role models and processes that promote equality and value diversity in the workplace.

Self-directed learning

• Role-played consultations, for example during teaching or courses, are valuable in exploring consultation behaviour in a safe environment, especially those using ‘standardised patients’ (played by actors or role players who have been trained to react in a consistent or specific manner).
• Peer group meetings are an excellent forum for you to discuss, in confidence, video consultations recorded in your surgery or using commercially available teaching packages.
• Some peer support groups, such as Balint groups¹, can offer a specific focus on the emotional content not just of single consultations but of ongoing doctor–patient relationships. This can help with managing your own wellbeing and developing the skills and self-knowledge you need to provide best care for patients.
• Book and web resources relevant to the GP consultation can be found in ‘Being a General Practitioner’.

Learning with other healthcare professionals

Consultations are the richest learning resource and can trigger multidisciplinary discussion about consulting skills, patient management, ethics, evidence-based practice, clinical guidelines and many other things. This can be achieved by observing or being observed during a live consultation, using role play or watching recorded consultations. Emerging integrated care pathways and multiprofessional team meetings offer valuable means of learning from the wider team, including social workers and secondary care consultants.

Applied Knowledge Test (AKT)

• Understanding and use of patient decision aids
• Confidentiality and disclosure of medical records
• Scenarios based on telephone, e-consultation and face-to-face consultations

Simulated Consultation Assessment (SCA)

• An older woman asks about options for euthanasia when her condition worsens; a hospital letter confirms her diagnosis of motor neurone disease
• A young person with diabetes has repeated admissions with ketoacidosis after ignoring instructions on managing her insulin
• Routine hormone replacement therapy (HRT) check for a 68-year-old woman with rheumatoid arthritis

Workplace-based Assessment (WPBA)

• Tutorial on dealing with angry patients
• Significant event about a patient who complained that you missed their diagnosis of bowel cancer
• Audio COT regarding a patient who believes they have a chest infection

References

1. Balint M. The Doctor, His Patient and The Illness Edinburgh: Churchill Livingstone, 1986