SCA toolkit: Data gathering

The opening of the consultation is important and sets the scene for the whole consultation. Therefore, if it goes badly, subsequent tasks can be adversely affected. A good opening contributes to establishing rapport and helps the patient to feel relaxed. The following behaviours all contribute to a successful opening:

• The trainee tells the patient their name, and explains their role in the practice
• The trainee demonstrates that they are interested in the patient
• The trainee’s non-verbal body language encourages the patient and helps them to feel comfortable and relaxed
• The trainee begins with an open question, such as “How can I help today?”
• The trainee does not interrupt the patient until they have said what they need to say
• The trainee stays focussed on the patient with good eye contact and positive non-verbal body language

The importance of successfully opening a consultation is particularly true for audio consultation. Audio consultations can go wrong at the outset, so it is important to:

• Speak clearly and slowly
• Introduce yourself
• Make sure you are dealing with the right patient
• Use modulations in voice to ensure that the patient remains engaged.

Another useful strategy is to check that the patient is able to talk freely - so with the right degree of privacy, and no competing responsibilities.

Activity 1

Record several videos and watch just the first minute of each consultation with your trainer. For each consultation check and discuss:

• Have I introduced myself, if necessary?
• Have I discovered the name of the patient, if necessary?
• Am I completely focussed on the patient in front of me? If not, why not?
• Do I seem interested in the patient?
• Do I let the patient speak or do I interrupt frequently?
• Have I started with an open question?

Activity 2

Compare the first minute of your consultation with the first minute of one of your trainer’s consultations. Do you observe and hear things that your trainer does differently that you can learn from?

Activity 3

Watch other consulters in the practice to identify different styles and to decide which approach suits your personal style.

Audio activity 1

Listen to four or five of your audio consultations, focusing on the first minute of each consultation. For each audio consultation ask yourself:

• Do I introduce myself clearly to the patient?
• Do I check that I am speaking to the right patient?
• Do I check that the patient is able to speak freely?
• Do I allow the patient to finish speaking?
• Is my first question to the patient an open question?

Exercise 1

Think about and discuss with your trainer different methods of greeting the patient. Which method do you think works best for you and helps the patient to feel comfortable and relaxed?

Exercise 2

Think about your own non-verbal demeanour. Remember that patients will make the same rapid evaluation of you in the opening 30 seconds as you do about them, so 70% of this evaluation is from your non-verbal communication.

In the case of audio consultations your non-verbal behaviour relates to the tone of your voice. For example, you can pair a friendly tone with carefully considered words in your opening greeting.

Exercise 3

Think about your ‘resting’ face and posture. Do you look overly serious and might benefit from smiling more? Think of your own physical presence and any potential barriers, such as a closed body posture or getting too close to the patient. What about the tone of your voice?

Exercise 4

Consider the option of shaking hands with a patient, which may work for you if you have a reserved approach, as shaking hands is often seen as a friendly introduction. Aim to find an approach which works for you and which you can adapt, depending on the patient’s age, gender and cultural background.

Obtaining information about psycho-social context is an essential data gathering task in the GP consultation. It is also very important to enable the sharing of patient-centred management plans.

Some trainees do not ask about psycho-social context at all, and some ask about it in a mechanistic way. This is often done without realising how important this information is for the management part of the consultation, and for the overall success of the consultation.

It’s important to be able to discover three things:

• The relevant psycho-social information from the patient, which includes aspects of work life and home life
• The impact of the problem on patient’s work and home life
• The way that home and work life impacts on the presenting problem

Patients may be reluctant to share psycho-social information over the phone - they may feel more time pressured than in a face-to-face consultation and may be reluctant to waste (as they see it) the doctor’s time. So you need to be prepared to ask about their home and work environment and the impact of their symptoms on their life.

Audio only can also be an advantage however, when it comes to discussing potentially sensitive issues such as a relationship or sexual history. Sometimes patients will feel more able to disclose this type of information when they are NOT face to face.
 
Audio allows you to write down information as the patient speaks, without being intrusive or disrespectful. This allows the doctor to recall psycho-social information for use later in the consultation.

Activity 1

Review a series of your consultations and write down how often you a) ask about psychosocial context and b) how often you use this information later in the consultation, particularly when talking about the management plan.

Activity 2

Practice the skill of remembering information about psychosocial context and storing it for use later in the consultation. 

Activity 3

Now devote some consultations where you specifically ensure that:

a)    you ask about psychosocial information

b)    you use that information to inform the management plan. Discuss any change by reviewing videos with your trainer.

Audio activity 1

Review a series of your audio consultations and any associated paperwork. In how many of these consultations do you:

a) ask about the patient’s psycho-social situation?
b) use this information later in the consultation? How does this success rate compare with your success rate in face-to-face consultations?

Do you find writing down psycho-social information helps you to use this information more later on in the consultation? Repeat and practice this process and see if you start to ask more questions about psycho-social context? Do you think it helps?

Exercise 1

If you often do not ask about psychosocial context - ask yourself why? Possible explanations are:

• You get absorbed in the ‘medical’ part of the consultation and either forget about psychosocial questions or feel awkward going back and asking. It is essential you do not ask about psychosocial context in a ‘tick box’ way as this impairs rapport. This is one reason why it is important to ask open questions - using open questions first allows a conversation where this information can be discovered in a more natural way. (Refer to the Toolkit section ‘Uses open questions appropriately’).
• You don’t understand the importance of exploring this area. Please see above, if you think of this as a ‘tick box’ you will not discover enough information about the patient’s life to share management options.
• Are you anxious about how to ask the question? or that doing so might ‘open a can of worms’ or irritate the patient? Discuss with your trainer.

Exercise 2

If you often don’t use the information about psychosocial context, ask yourself why? Discuss with your trainer. Possible answers are:

• You forget the information that you have discovered about psychosocial context so you can’t use it later in the consultation
• You lack the skill to introduce the information later in the consultation
• You are already overwhelmed with the complexities of sharing diagnosis and management plan

Identifying cues (verbal and/or non-verbal) helps the doctor to understand the patient’s ideas and concerns about the presenting problem. Patient cues will invariably offer ‘clues’ to information that is relevant to the diagnosis and therefore form an important part of data gathering. For example, a patient who talks slowly and with a depressed tone, may be suffering from low mood. A patient’s opening statement will often contain verbal cues such as
- “I was wondering if my headaches needed to be investigated” or - ‘I’ve been feeling very down since my father died”. This almost always provides valuable information about why the patient has attended.

It is sometimes difficult to detect cues on the telephone - you cannot see the patient so it is very easy to miss out on non-verbal cues, and even verbal cues may be missed if there is a poor signal or interference on the line. So - you need to carefully practice the skills involved in detecting cues (as below) and be prepared to ask additional questions if you suspect a patient is presenting you with a cue.

Activity 1

Watch a series of your videos with your trainer - write down all the possible cues you can see in these consultations and compare your list with your trainer. Remember to do some videos focussing the camera on the patient and note non-verbal cues as well as verbal cues.

Activity 2

If there are cues that you did not notice (but your trainer did) discuss with your trainer what prompted the insight that a particular verbal or non-verbal behaviour was a cue. Make a list of these insights.

Activity 3

Now keep practicing the skill of cue detection using the insights obtained from Activity 1 and 2. After a while, repeat the comparison exercise with your trainer to see if you are improving.

Activity 4

Remember the huge importance of being curious (Refer to the Toolkit section on ‘Listens and shows curiosity’).

Activity 5

Now spend some time working on your consultations and videos, trying to identify more cues and discuss this with your trainer.

Audio activity 1

Listen to a series of your audio consultations with your trainer or an experienced consulter. Each of you write down whenever they think the patient is presenting a cue. Now compare lists. Are you failing to detect cues that your experienced colleague detected? Now write down what it was that alerted your colleague to the cues that you missed. Using this information, practice the skill of ‘cue detection’ on further audio consultations.

Now compare your success rate in detecting cues between audio consultations and face-to-face consultations. Are you better at detecting cues in face-to-face consultations or audio consultations?

Exercise 1

Why do you think there is a difference between cue detection in audio consultations and face-to-face consultations? What could you do to reduce or even eliminate this difference?

It is important to remember that discovering ICE is not just a ‘hoop’ that you are expected to jump through. Understanding the patient’s reasons for attending is a vital part of developing an effective management plan and consulting well. In the majority of GP consultations, it is essential to understand the patient’s ideas, concerns and expectations. Without this information it is very difficult to make a well-informed working diagnosis or involve the patient in the management plan, safety netting and follow up.

Patients may feel uncomfortable with what they see as wasting the doctor’s time, so may be less confident in volunteering ICE. You have less opportunity to make them feel comfortable and encouraged, as the only non-verbal method you can use is the tone of your voice. Some patients however are more relaxed on the phone, and may be more likely to share information about their ideas and concerns.

Activity 1

Review a series of your consultations and see whether you discovered all three of:

• Ideas
• Concerns
• Expectations

Make sure all three components of ICE are present - they are not interchangeable, and each part of ICE provides different information. It may however not be necessary to ask ‘directly’ as encouraging a patient narrative or ‘story’ with open questions often results in spontaneous offering up of ICE.

Activity 2

Watch your trainer consult in a joint surgery and write down how he/she finds out about the patient’s ICE. Do you use the same phrases and expressions? Are there any useful phrases or questions from your trainer that you can use yourself? If so, write them down.

Activity 3

What happens when the patient spontaneously volunteers ICE? How does the trainer facilitate this?

Activity 4

Now devote a series of consultations to specifically incorporating these questions into your routine patient questioning - video some examples of this and discuss with your trainer. What works and what doesn’t work?

Activity 5

Now practice introducing the questions in as natural a way as possible (discuss with your trainer) paying attention to the right time to introduce the questions (NOTE: there is no absolute rule about the best time to do this) You need to maintain a natural flow and questions should not be unexpected or seem ‘random’.

Activity 6

You can practice asking about ICE in normal conversation with friends and family - but warn them first what you are doing, or they may wonder why you have adopted a new way of talking to them.

Activity 7

When you have been practicing these changes for a while, compare a recent video or audio consultation to an older consultation. Hopefully, the new consultation will be less clunky, jarring or awkward. Write down the main differences that are making your approach more fluent and continue to work on these changes.

Audio activity 1

Review a series of your audio consultations and see how often you ask the patient about ideas, concerns and expectations, and how often you discover relevant information from this process. Now compare your success rate of discovering ICE with your success rate in face-to-face consultations.

Do you write down the information that you gain from asking questions about ICE? Does this help you to use the information later in the consultation?

Exercise 1

How often do you obtain information about ICE just from the information offered by the patient? (Without asking directly for this information?). What other consultation skills might help the patient to provide information about their ideas concerns and expectations? Refer to the corresponding IPS section of the toolkit for some additional suggestions.

Exercise 2

How can you avoid asking about ICE in a clunky or insensitive way? Is it easier to discover both ICE and psychosocial context when the consultation is still ‘open’ at the start and the patient is ‘telling their story’? Do you find out about ICE in a way which avoids either damaging rapport, or being patronising or perhaps ‘jarring’ at inappropriate points in the consultation?

Exercise 3

How seriously do you take ICE? It can be easy to fall into a trap of seeing it as ‘something that needs to be done’, but this risks it not being taken seriously enough. It should be given the same time and care as taking a medical history.

• Examinations (and tests) may be available from prior consultations with another health care professional or the patient themselves undertaking self-testing, such as blood pressure monitoring, blood glucose readings or taking a photograph.
• Start to think of any examinations (and tests) in the same way as you think about taking a history - their role is to assist with ruling in or ruling out particular diagnoses and sometimes to reassure the patient about a particular concern. A few examinations can be done either on the telephone or during a remote video consultation, such as tests of cognitive functioning and mental health including suicidal risk assessment. A photograph of a dermatology condition may also be submitted previously, requiring interpretation.

The main formal examination type in an audio consultation is the mental state examination. However, you can often gain valuable information from listening carefully to the patient over the phone.

For example, you can gain much information about a child based on reports from their guardian of their degree of movement and activity. For an adult, breathlessness or difficulty speaking on the telephone can indicate respiratory distress, hoarseness may indicate a cause for concern and any speech problems. All are valuable examination findings that can be used to inform the diagnostic process.

If you have been sent a photograph beforehand, you also have the option of describing what you see on the photograph and how the findings might rule in or out serious disease (or not).

Activity 1

Review a series of your consultations. In how many of these consultations is there evidence of your interpretation of examination/tests helping with hypothesis testing?

Activity 2

When you review your video and audio consultations, ask yourself - “How effective is my interpretation of any examination or test findings in clarifying the diagnosis?” Think particularly:

• Is the examination/test from a reliable and recent source? (for example, the 6CIT test for cognitive impairment)
• How did the examination/test findings inform my diagnostic process?
• Were there any gaps in my knowledge whilst interpreting examination/test findings? If so, how did this affect the diagnostic process?

Activity 3

Now practice this approach in your future consultations and review some of these consultations with your trainer. Do you feel the accuracy of your diagnostic process has improved?

Audio activity 1

Review a series of your audio consultations. Could you obtain more information about the patient by judicious use of questions and asking the patient to perform simple tasks? In each consultation, have you maximised the information you have obtained from the limited examination that you and the patient can do over the telephone? How have you used your interpretation of any examination/test findings to rule in or out diagnoses?

Exercise 1

When do you think is the best time to share information about the results of examinations or tests? What are the pros and cons of sharing information about examinations/tests at different points in the consultation?

It is important to demonstrate a safe and thorough approach to making diagnoses. Here’s the approach to take:

• Generate a list of differential diagnoses based on the presenting symptom or problem. A lot of this information will come from open questions, but you will supplement this with closed questions (see Toolkit sections ‘Uses open questions appropriately’ and ‘Uses closed questions appropriately’) and with examination and investigation findings.
• Use a series of closed questions to test each hypothesis and weigh up its likelihood. Using this approach you can establish a rough-and-ready ranking of diagnoses, based on their likelihood.
• You will also need to specifically rule-out or rule-in serious disease by the use of closed questions - see the toolkit section: ‘Rules in/out serious disease’.

In an audio consultation, you have less supporting information than in a face-to-face consultation. Unless you ask the patient to come to the surgery, you do not have the benefit of an examination, or access to any local tests such as urinalysis or pulse oximetry. So, it’s even more important to generate an accurate list of possible differential diagnoses and ask discriminating questions in order to discover the most likely diagnosis. This will help you decide what to do next - give advice, see in surgery, or refer to another provider.

Important: When consulting via audio, please resist the temptation to miss out the process of generating diagnostic hypotheses. You might think that once you have decided to call the patient in for a face-to-face consultation (or not) you can stop thinking about diagnostic hypotheses. But this stage is vital - it will inform the urgency of your next step and may determine your plan for the next part of the consultation.

Activity 1

To check your ability to identify a realistic list of differential diagnoses watch/ listen to a series of consultations with your trainer where you and your trainer write down a list of plausible differential diagnoses for the presenting problem. At the end of each consultation compare lists with your trainer. If you are regularly missing possible diagnoses, then ask yourself (and discuss with your trainer) whether you are missing particular sorts of differential diagnoses.

The authors of this guide have found that the use of publications which focus primarily on the analysis of patient symptoms is very helpful, and prevents the doctor from missing important diagnoses. One such publication that the toolkit authors have found helpful is the book ‘Symptom Sorter 6th Edition’ (2020) by Keith Hopcroft and Vincent Forte.

Activity 2

Using the Super-condensed Curriculum and (for example) ‘Symptom Sorter 6th edition' (2020), write down a list of presenting symptoms for which you would find it challenging to generate a list of differential diagnoses. Practice producing useful and discriminating questions for these symptoms. Role play is very useful to cover rarer differential diagnoses.

Activity 3

Work with your peer study group. Make a list of some commonly presenting problems or symptoms, for example: Tired all the time, epigastric pain, pain in the leg etc.

Take it in turns to think of a different patient presenting with these problems and how the age and sex might affect the list of differential diagnoses that occur to you initially. For example, a woman aged 46 years with ‘tired all the time’, you might think of 1) Anaemia due to heavy periods, 2) Stress/low mood, 3) Thyroid disorders as the top 3 most likely differentials.

This is a particularly important exercise if you have changed medical careers or are less experienced in UK general practice.

Activity 4

Repeat Activity 3 above, generating ‘red flag’ questions for a list of serious differential diagnoses. An example of a red flag scenario might be cauda equina syndrome when the presenting symptom is back pain.

Note: There is more information about red flag questions in the ‘Rules in / out serious disease’ section of this toolkit.

Exercise 1

Your diagnostic hypothesis testing must be efficient and ‘good enough’ for safe, independent practice.

• Reflect on any gaps in your knowledge of UK medicine.
• Undertake a curriculum self-assessment, using the headings from the RCGP curriculum.
• In areas where you are less confident around your level of diagnostic knowledge, discuss in your peer study group and with your trainer.
• What methods of improving your knowledge can you use? NICE, clinical knowledge summaries, GP library on FourteenFish are all useful resources.
• Also consider using PUNS (Patient Unmet Needs) during consultations to generate and guide your revision by producing DENS (Doctor’s Educational Needs)

When developing differential diagnoses, it is important to ensure that serious disease is ruled in or ruled out. This is achieved by actively seeking the presence or absence of symptoms which are associated with serious disease — the so-called red flags. This is particularly important for serious but less probable diseases that could have catastrophic sequelae if missed.

Red flag symptoms provide information about the presence of serious diagnoses for which diagnostic delay is not acceptable. They can be detected by the use of open or closed questions.

Example: When assessing a patient with the presenting symptom of back pain, it is important to specifically ask about red flag symptoms such as: urinary incontinence, faecal incontinence, saddle anaesthesia, weakness or paralysis affecting more than one nerve root.

In an audio consultation, you have less supporting information than in a face-to-face consultation. Unless you ask the patient to come to the surgery, you do not have the benefit of an examination, or access to any local tests such as urinalysis or pulse oximetry. So, it’s even more important to think about the possibility of serious disease and ask about red flag symptoms. This will help you decide what to do next and to assess the urgency of any medical intervention.

Important: When consulting via audio, please resist the temptation to omit the process of ruling in or out serious disease. In particular, you might think that once you have decided to call the patient in for a face-to-face consultation (or not) you can stop thinking about serious disease. But it is important to keep the possibility of serious disease at the forefront of your mind - it will inform the urgency of your next step.

Activity 1

To check your ability to rule in or rule out serious disease, watch/listen to a series of consultations with your trainer where you and your trainer write down a list of possible serious conditions that are consistent with the presenting symptoms. At the end of each consultation compare lists with your trainer. If you are regularly missing possible serious diagnoses, then ask yourself (and discuss with your trainer) why this is the case. The authors of this guide have found that looking up symptoms in (for example) ‘Symptom Sorter 6th edition' (2020) is a good way to make sure you are not missing important diagnoses.

Activity 2

Using the ‘Super-condensed Curriculum’ and (for example) ‘Symptom Sorter 6th edition' (2020), write down a list of presenting symptoms about which you are unsure about how to rule in or rule out serious disease. Practise producing useful and discriminating questions for these symptoms. Role play is very useful to cover rare (but serious) differential diagnoses.

Activity 3

Work with your peer study group. Make a list of some commonly presenting problems or symptoms, for example: tired all the time, epigastric pain, pain in the leg etc.

For each symptom, write down the serious conditions associated with each problem or symptom. Once you have done this, write down the questions you could use to rule in or rule out each serious condition. Now role-play consultations with colleagues and practice the process of effectively ruling in and ruling out serious disease.

An example might be a patient with back pain when the serious condition you need to rule out is cauda equina syndrome. The questions to think about would be:

• Is there evidence of urinary retention?
• Is there evidence of urinary or faecal incontinence?
• Is there evidence of saddle anaesthesia?
• Is the patient aware of sensation when they wipe their bottom?
• Is there evidence of weakness or paralysis involving more than one nerve root?
• Is there any evidence of change in sexual function?

Audio activity 1

Review a series of audio consultations. In how many of these consultations did you think about possible serious disease, and in how many of these did you ask appropriate questions to rule in or rule out serious disease?

Exercise 1

Your knowledge of serious disease must be ‘good enough’ for safe, independent practice.

• Reflect on any gaps in your knowledge of UK medicine.
• Undertake a curriculum self-assessment, using the headings from the RCGP curriculum.
• In areas where you are less confident around your level of diagnostic knowledge, discuss in your peer study group and with your trainer.
• What methods of improving your knowledge can you use? NICE, clinical knowledge summaries, GP Library on FourteenFish are all useful resources.

This part of the consultation is often done badly in GP consultations. In order to do well in this part of the consultation, you need to:

• Reach a ‘working’ diagnosis/analysis
• Make sure the diagnosis is correct (or as correct as is possible given the information available in the case) - this is what is meant by a ‘working’ diagnosis.
• Reach an analysis of the problem where a diagnosis has already been made. The consultation may be presented to you by a third party, for example a carer.
• Tell the patient what the ‘working’ or provisional diagnosis is (refer to the toolkit section ‘Verbalises diagnosis and/or analysis’ for more information about how to do this)

It’s vital to get the diagnosis right. Making a wrong diagnosis makes it very difficult to produce an appropriate management plan for the patient’s problem. Many wrong diagnoses arise from insufficient knowledge, in particular:

• Incomplete knowledge of possible diagnoses
• Inadequate knowledge of the key diagnostic differences between diseases. Don’t make your diagnosis too early.

Sometimes inaccurate diagnoses originate from illogical decision-making - even when the trainee has enough knowledge, and asks the right questions, they reach a diagnostic decision that is not based on the information gained. This is often because the diagnosis has been made too early in the consultation and the trainee is not prepared to revise this diagnosis as new information emerges.

When the diagnosis has already been made prior to the consultation, make sure that you reach an analysis of the current problem. This will enable you to plan your management with the patient.
 
This part of the toolkit relates to making or reaching the (correct) diagnosis or diagnoses. See ‘Verbalises diagnosis and/or analysis’ for information about communicating the diagnosis to the patient.

Reaching a diagnosis is often harder in an audio consultation because there is less information available. (for example, no ‘live’ examination findings, no information from non-verbal cues).

There may however, be existing examination findings and tests available and the working diagnosis can be formed from the additional history gained during the consultation.

Some audio consultations may require an analysis of the problem rather than a specific ‘working’ diagnosis. An example would be where a diagnosis has already been made, and the patient is presenting with a worsening of their symptoms or a request for different management. One such scenario might be the patient with Polycystic Ovarian Syndrome and infertility who is wanting to conceive. Another might be hypertension with deteriorating blood pressure control.

Activity 1

Review a series of your consultations. How many times do you a) make a working or ‘provisional’ diagnosis and b) share this with the patient?

Activity 2

Reflect on how not making a clear working diagnosis might affect the management part of the consultation. Discuss this with your trainer and observe how often your trainer offers a working diagnosis during their consultations. Refer to relevant sections in the toolkit ’Verbalises diagnosis and/or analysis’ and ‘Shares and use ICE in plan’

Activity 3

Now practice a series of consultations where you pay particular attention to the importance of making and sharing a diagnosis. Reflect on how this might affect the effectiveness of the management plan.

Activity 4

Carry out a needs assessment of your knowledge gaps. Do this by looking at the GP clinical topic guides in the GP curriculum section on the RCGP website. 

Activity 5

Make sure you are seeing the right sorts of cases, based on the needs assessment above. Speak to your trainer and/or senior receptionist to make sure you get the right clinical exposure for your needs. If all else fails, get your trainer to role play the types of cases you need to see or other doctors in a peer study group, record the role play and discuss with your trainer.

Activity 6

Develop this routine. Whenever you see a patient who has a symptom that you are unsure about, or where you are not sure which questions to ask to clarify the diagnosis - write this down. Then afterwards (as soon as possible) read up or discuss with colleagues and hence improve your knowledge about this particular part of patient care.

Activity 7

Review a series of consultations with your trainer. How often is your diagnosis or diagnoses different to that reached by your trainer. Reflect on why this is happening.

Activity 8

Watch a consultation where you and your trainer reach a different diagnosis (it does not necessarily have to be yours) and go through the decision-making process in detail. Find out where you and your trainer diverge in decision-making and reflect on this.

Activity 9

Now address these issues and repeat the process in 5) above. Is the gap between you and your trainer becoming less?

Audio activity 1

Review a series of your audio consultations. How sure are you of the diagnosis or analysis of the problem you have made?

Do you feel less confident or more confident about diagnoses reached in an audio consultation, compared with a diagnosis reached in a face-to-face consultation?

What extra information could have increased your confidence in these diagnoses?

Exercise 1

Think about other ways of increasing your clinical exposure in weak knowledge areas. This may require you to see (for example) patients with nurses in chronic disease clinics or women’s health or sexual health for example.

Exercise 2

Do you think that your patient believes and agrees with your diagnosis? What are the consequences if the patient does not believe and/or agree with your diagnosis? How could you improve the success rate of patients accepting your diagnosis?