SCA toolkit: Global skills

A structured consultation is helpful for both doctor and patient. For the doctor, it provides confidence that the consultation has been complete, comprehensive and thorough. For the patient, it is reassuring that the consultation does not throw up surprises or unexpected changes in direction.

To achieve a structured consultation, the doctor needs to have an overall plan for the aims and direction of the consultation. However, this should not be followed in a rigid way - always make time in your consultation to take the consultation in a direction dictated by the patient. (Refer to the Toolkit section ‘Remains responsive to the patient’.)

There are several techniques to produce structure in the consultation. These include laying out the plan of the consultation. Summaries can be a useful strategy, particularly when the history or plan has been complex. Signposting (explaining what is coming next in the consultation or explaining the reason for a particular line of questioning) is helpful if there is going to be a sudden change of direction, or a move into emotionally sensitive or unexpected areas.

Structure within the consultation is equally important during audio consultations. Because you are not sitting alongside the patient, but instead relying purely on verbal exchange of information, there is a greater possibility for confusion and lack of structure within the consultation. It is therefore important to signpost regularly within an audio consultation and offer short summaries when there is any possibility of lack of clarity.

Activity 1

Review a series of your consultations with your trainer and write down the areas that you feel may be contributing to poor structure. In particular, consider:

• Is there a logical progression of tasks through the consultation? (see Toolkit section ‘Progresses through tasks’ for more information)
• Are any helpful summaries offered at appropriate times in the consultation? (typically, after a period during which there has been an exchange of complex information)
• Is there evidence of ‘signposting’ when there is a sudden change of direction, or where there are questions that are personal or emotionally sensitive

Discuss this assessment with your trainer or with an experienced colleague. Pay particular attention to situations where your assessment differs from that of your colleague.

Activity 2

Now try to eliminate these causes of lack of structure - using the information and in other areas of this Toolkit. You might want to do this one problem at a time and get one part of the consultation well-structured before you apply this to the whole consultation. When you feel you are making progress, the consultation to your trainer or colleague. Ask the questions - “Is this consultation more structured than before?” and “What areas do I need to work on?”

Audio activity 1

Do you think your audio consultations are as structured as your face-to-face consultations? If not, why is there a difference? Review a series of audio consultations and try to identify why the consultation becomes unstructured. As for the face-to-face consultations, ask is this due to - lack of logical progression - absent or inappropriate summaries - absence of signposting?

Exercise 1

Do you agree that a structured consultation is important? What is the effect on patient care of an unstructured consultation? Can you think of any other methods to improve the structure in a consultation?

Repetition of questions can really damage the consultation.

• It signals to the patient that you are not listening to the patient - which in turn signifies a lack of interest, concentration or respect.
• It also wastes time, irritates the patient (which makes them less likely to answer future questions helpfully)
• It prevents you from building up an accurate picture of the patient’s problem.

What are the reasons for repeating questions? Here are some possibilities:

• You are thinking of the next question to ask, and therefore do not fully register the patient’s response.
• Your concentration is impaired, and this causes disorganised questioning
• Your initial question is badly phrased, and the patient does not fully understand what you are asking
• You are puzzled by the patient’s reply but fail to explore this at the time
• You are tempted to go over previous material when you do not know what to do next

Sometimes trainees repeat whole sections of the consultation, if they are not completely confident that they have adequately tackled previous parts of the consultation. For example, after discussing the diagnosis some trainees say: “I’d just like to ask you a few more questions”.

It is particularly easy to repeat questions in audio consultations, where the level of concentration needed is higher, and where you are less aware of non-verbal cues which alert you to the fact that the patient may be frustrated by this repetition. Sometimes, however, you may need to repeat a question. For example, if you cannot hear a patient response due to a poor line, or when something is so important that you have to repeat the question in order to clarify a piece of information. In such situations, make it clear to the patient why it is necessary to repeat the question.

Activity 1

Video several of your consultations and review them. On a piece of paper, write down every question you ask in each consultation. You will end up with a list of questions. Now review your list - how many times have you repeated a question? Ask yourself why you have repeated questions? Did you not hear the answer the first time? Did you not understand the answer the first time? Were you thinking ahead of the next thing to ask? Were you just filling in a hiatus in the consultation?

Activity 2

Now repeat the process and try to completely eliminate all repetition of questions. You will need to listen carefully to the patient and explore any replies that you do not fully understand. Repeat the process in (1) of making a list of all questions and checking for repetition.

Audio activity 1

Review several of your audio consultations. Do you repeat questions? If so, is there something about consulting via audio that causes you to repeat yourself. Do you think that the problem of repetition is more likely in face-to-face consultations, or in audio consultations? Why? Are there any techniques available to avoid repetition in audio consultations?

Do you always explain to the patient why there is repetition?

Exercise 1

Can you think of any situation where repetition may improve the consultation?

Exercise 2

What about the patient? What does it mean when patients repeat information? What should you do if a patient seems to repeat certain pieces of information, or repeatedly asks the same question?

Progressing through the tasks in a consultation in a logical order is very important, in particular  to enable a thorough assessment of the problem and to have time for a discussion of a patient-centred  management plan.

Problems with this global skill, commonly occur when other interpersonal skills are poorly  executed at the beginning of the consultation. Poor active listening skills, failing to achieve a  good balance of open questions and premature use of closed questions, will all result in the  incomplete discovery of patient-specific information. Without this information, the doctor will  struggle later in the consultation to involve the patient in any proposed management plan or  approach. Moreover, failing to discover patient psychosocial information may well also impair  the diagnostic process.

The failure to progress through these data gathering tasks will therefore have a direct impact  on making a working diagnosis and sharing the management and the doctor may attempt to  ‘double-back’ to try and elicit the information. This approach is rarely successful as the  questions will seem mistimed and ‘clunky’, confusing the patient and damaging rapport and  patient concordance.

Even if the information is forthcoming at this late and inappropriate point in the consultation,  the re-visiting of earlier tasks will have an adverse impact on time management.

This global skill is equally important during an audio consultation. Problems with specific tasks such as ‘Discovers psycho-social context’ are likely to be more prevalent in audio consultations as outlined under these sections in the Toolkit.

Activity 1

First identify how good you are at progressing through the tasks in the consultation, by analysing a few different consultations. Perhaps write the tasks out on a timeline and ‘map’ each one by placing a cross when you feel that the task appears in the consultation.

You may find that tasks such as ‘Discovers patient ICE’ are appearing more than once, for example. Have another listen to the consultation with your trainer and try to identify which of the individual interpersonal skills needs improving to make sure you deal with the task adequately the first time.

Activity 2

Use the RAG Rating Grid to rate a few consultations. Now look at those tasks you have rated RED. Take them in turn and discuss with your trainer why you felt the rating was RED. If it is due to omitting that task, consider that a complimentary interpersonal skill may have been poorly executed. A common example might be that you fail to discover patient’s psychosocial context and when you look at the related interpersonal skill ‘Uses open questions appropriately’ find you asked only one open question.

Activity 3

Ask your trainer if you can watch/listen to a couple of their consultations. Note how they progress through the tasks (use the Grid if you like). Watch where they complete 3 tasks in particular- ‘Discovers psycho-social context’, ‘Identifies cues’ and ‘Discovers patient’s ICE’.

How flexible is their approach? Are these tasks all located in the data gathering(first)part of the consultation? What happens if they are omitted or skipped initially, but appear later on?

Try a role play and discuss what happens when you come to sharing the management plan without patient information like ICE?

Audio activity 1

The activities above can be used equally effectively to analyse where problems are occurring, and individual sections subsequently consulted to help modify behaviours and improve skills.

In addition, try the following activities:

Are there any blocks in your audio consultations? As discussed elsewhere in this Toolkit, ‘map’ the consultation and see if you can see any patterns in your consultations? Things to look out for are:

• Tasks that are missing altogether
• Tasks that seem to be ineffective or confusing to the patient
• Tasks that you seem to repeat

Why do you think this is happening? You may need to discuss this with your trainer or experienced colleague.

Exercise 1

Discuss with your trainer each of the tasks on the RAG grid. What are your thoughts about the importance of each to the overall outcome at the end of the consultation? What are your thoughts about the effect of omitting some or one of the tasks-are they all essential? Discuss the tasks ‘Discovers psycho-social context’, ‘Identifies cues’ and ‘Discovers patient’s ICE’. What are your thoughts about these 3 tasks? How important is their position in the timeline on the RAG Grid?

Ethics is a part of almost every general practice consultation. Learning to practice ethically is demanding and difficult. There are two components to practicing ethically:

1. Understanding what matters ethically
2. Making ethical decisions

Understanding what matters ethically

It is useful to have a framework for thinking about all the ethical issues of importance in a consultation. Here is one such framework, known colloquially as the ‘Four Principles’.

The Four Principles are: respect for autonomy, beneficence, non-maleficence and justice.

The basic idea is that you should practice medicine in such a way as to be consistent with all four principles. Of course, sometimes these principles conflict with each other, and when this happens it is important to be able to justify the choice of one principle over another.

Respect for autonomy

• Shared decision-making
• Avoiding medical paternalism. Medical paternalism occurs when doctors interfere with a patient decision, against the patient's will, on the grounds that the patient will be better off or protected from harm
• Respecting confidentiality and privacy
• Being aware of situations where autonomy might not apply e.g. when the patient lacks capacity

Beneficence

• Effectively treating medical problems
• Effectively offering preventative medicine
• Comforting the patient
• Empathising with the patient

Non-maleficence

• Avoiding iatrogenic harm
• Avoiding false reassurance
• Avoiding causing unnecessary alarm and fear

Justice

• Avoiding discrimination based on age, race, sex, gender etc.
• Using limited resources in a careful way
• If there has to be rationing, providing this in a transparent and fair way

Making ethical decisions

There are several components involved in making justifiable ethical decisions. You need to develop and internalise a framework for making justifiable ethical decisions. Here is a nine-stage framework which you may find helpful.

Nine-stage ethical framework

1. Recognise that an ethical issue is present
2. Collect any extra relevant information that you might need and mentally summarise the situation
3. Sometimes there is only one reasonable ethical option, and it is very easy to decide what to do. But if there is conflict between ethical principles:
4. Brainstorm all the possible options (even if they are initially unpromising)
5. For each of your options list the ethical advantages and disadvantages
6. Now consider:
   1. Is there anything I can do to resolve the ethical conflict? (for example, if a patient does not want to tell a partner about a STD, try and persuade the patient to do so, give reasons why this is important, offer a joint consultation, etc.)
   2. Is there any professional guidance about the ethical decision? (good sources are the GMC, the BMA, the protection societies)
   3. Can you ask for a second opinion?
7. After considering all the above factors - make a decision. Remember that there may be no ‘perfect’ decision, and you may have to settle for the ‘least bad’ decision
8. Communicate your decision to all those individuals are affected
9. Keep accurate records

Ethical considerations are equally important during audio consultations as they are in face-to-face consultations. Sometimes practicing ethically within an audio consultation can be quite difficult. One reason for this is the loss of information about what the patient is thinking this makes it harder to respect autonomy. So it’s important to spend time on the phone checking that the patient is happy with a particular management plan, and carefully exploring cues and partially expressed concerns and expectations.

Activity 1

Review a series of your consultations with your trainer. As you watch the video(s), identify any ethical issues that appear, and write them down. After this exercise, compare your list of ethical issues with the list produced by your trainer. Are there some ethical issues that you are regularly missing? (This educational activity focusses on Step 1 of the ethical framework above)

Activity 2

As you encounter ethical issues or dilemmas in your work, make a note of them and consider the following questions:

• What extra information did I need to collect?
• What were my options in this situation?
• What are the pros and cons of each option?
• What guidance do I know about for this situation?
• What was the best thing to do in this situation?

Activity 3

Now share your analysis of these ethical dilemmas with your trainer. What would they have done in these situations? If there is a difference in what you would have done and what your trainer would have done, think why this is the case?

Audio activity 1

Now repeat the above exercises with a series of audio consultations. Is there a difference between your decision-making in face-to-face consultations and your decision-making in audio consultations. If there is why do you think this is the case? Do you think you are systematically missing out ethical considerations in your audio consultations?

Exercise 1

Construct your own ‘Ethical framework’. What do you think are the key steps in making an ethical decision? How do you balance competing ethical principles if they pull in different directions?

During a 12-minute consultation, it is important to allow enough time for a safe patient centred management plan to be shared and outlined. Appropriate safety-netting and follow-up need to be completed too. Doctors who struggle to reach this point, commonly spend more than 6-7 minutes on data gathering tasks.

It can be easier to fit in quite a lot of clinical management options into only 4 minutes of an audio consultation, but only if the structure of the preceding data gathering section has been well organised and comprehensive. This guidance ‘by 6-7 minutes’ can therefore be more loosely applied and this is often because a clinical examination is a smaller part of the consultation, but conversely the history taking may need to be longer as there are no visual cues.

The global skills of ‘Structures consultation’ and ‘Progresses through tasks’ may be more likely to be diagnostic of problems in an audio consultation as a result.

Activity 1

If you are scoring red or amber for this skill over a series of consultations, try and breakdown what you are doing during data gathering. Are you progressing through the tasks? Have a look at the ‘Progresses through tasks’ global skill descriptors if you are not sure.

If you are not progressing through tasks, try and analyse why not. Commonly this is due to poorly executed interpersonal skills in the data gathering section see Activity 2.

Activity 2

Consider, is the problem due to...

• Too early use of closed questions?
• Failing to detect cues and/or failing to explore cues?
• Poor listening?
• Repetition of questions and comments?
• Too much or ‘overzealous permission seeking’? (see ‘Uses closed questions appropriately’)
• A tendency to ask a lot of questions "just in case you might miss something”?
• Offering indiscriminate clinical examination and/or tests?

Now produce a written list of these problem areas and tackle them one by one video/ record any changes you make and let your trainer see them. Look at individual sections of the interpersonal skills to help you change your behaviours, in particular the interpersonal skills below:

• ‘Identifies cues’
• ‘Uses open questions appropriately’
• ‘Clarifies and explores cues offered’
• ‘Uses closed questions appropriately’

Activities 1 and 2 are useful activities to work through, if a doctor repeatedly fails to finish by 6 minutes. In addition, try the following activity.

Audio activity 1

How long do spend on data collection in audio consultations? Review a series of audio consultations and measure the time it takes to completely finish data collection. Is this period shorter or longer than in your face-to-face consultations? If the time period is shorter, think why this might be the case?

Now consider how you could use the extra time to make the consultation more effective and satisfactory. Consider some options:

• More time spent on open questions
• More time spent on exploring cues
• More time spent on asking about ICE and psychosocial context
• More time spent later using ICE/patient info in sharing the management plan

Exercise 1

What might be the effect of taking longer than 6-7 minutes to complete data gathering? How might that impact the rest of your consultation a) In the SCA examination and b) In real life?

Exercise 2

Some trainees cope with a long data collection period by coming back to data collection later in the consultation in effect they split data collection into two parts. Is this a good idea? What do you think are the implications of doing this a) In the SCA and b) In real life?

Using confusing or over-technical language may prevent the patient being involved in the consultation and damage rapport. Language also needs to be adapted to allow for the patients’ educational level and cultural context and this is impossible to achieve unless you have discovered the patient’s psychosocial information and ICE.

If a patient does not understand a diagnosis and subsequent management, they may also feel unsupported and the outcome of the consultation will be unsatisfactory. Similarly, if a patient does not understand the reasons for follow up and when to reconsult, this could produce patient safety issues.

Verbalisation or ‘thinking aloud’ is an important complementary interpersonal skill and will be more effective if you use clear language during your verbalisation.

Mastering this global consultation skill should therefore be a priority and it can be easily practised and improved with the exercises below.

Using clear language is even more important during an audio consultation as you have no visual cues to help assess if a patient has understood you. Moreover, the quality of sound needs to be good and there may be barriers with strong accents that are amplified on the telephone.

Activity 1

Use your patients.

• Ask patients if the explanation you have just given is clear. If they say no, or seem unsure, ask them why not?
• If you notice them looking down, or losing eye contact during an explanation, check if you have confused them.
• During audio consultations, be aware that a silence or a hesitant response may mean that the patient has not understood.

Take care not to be too interrogatory though, as a patient may be embarrassed that they have not understood their doctor and may need coaxing to admit it.

Try and rerun the explanation, if time allows, so you can improve your skills and help the patient to understand. Or make a note of the explanation you struggled with and practice a rerun with peers as Activity 5 below.

Activity 2

Try to use a patient's language in the consultation, for example if the patient says “I think this is down to stress, I’ve been feeling under a lot of pressure recently”, use “You mentioned you put this problem down to stress, due to the pressure you have been under recently...” Practise in role play scenarios with your trainer. This works effectively for audio consultations too.

If you struggle to do this, look at the section on ‘Identifies cues’ and ‘Clarifies and explores cues’, and improve your use of patient cues.

Activity 3

Show your video/audio recording (with the patient's permission) to non-medical and medical colleagues - do they think your explanation is clear and not ambiguous? What phrases would they use?

Activity 4

Practise with friends and family, explaining conditions and management plans - ask them if they understood. You can download patient information leaflets from NHS patient.info. These leaflets use clear, simple language to describe conditions and their management.

Activity 5

Practise in your peer study groups. Come up with a list of common conditions and practise explaining the diagnosis of these conditions and the management. This may be particularly important if your first language is not English and also if you have changed career from a hospital specialty. Hospital doctors tend to use more medical jargon and technical language so you may have slipped into this habit. If English is not your first language, you may need to ask peers for phrases and words in English.

Use the activities above to focus on improving your use of clear language during all tasks but in particular during clinical management.

In addition, try the following activity.

Audio activity 1

Use your patients to help with this part of the consultation. At the end of audio consultations ask patients two questions: a) was there anything that they did not hear and b) was there anything they did not understand?

The patient’s ability to hear may be outside your control, but most problems can be at least alleviated if you concentrate on speaking more clearly and more slowly.

If an audio consultation patient tells you that they have heard you, but not understood you, then it is important to make sure you use simple and non-technical words and phrases. There are tips on how to do this in the material and activities above.

Exercise 1

What do you understand by the term ‘Clear Language’? What do you think are the components of clear language?

Exercise 2

Reflect on how would you ‘use clear language’ when explaining a particular medical condition to:

1. A patient with a learning disability
2. A patient with a hearing impairment
3. A patient for whom English is not their first language
4. A patient whom you feel has not understood what you have said so far?

Being responsive to the patient is an important component of consulting effectively.

Without responsiveness, the patient consultation will appear insensitive to the patient, jarring and possibly even rude or hostile.

More importantly, the patient will feel that he/she is not being listened to - and will therefore be less likely to engage with the consultation or share important information. Or even worse - may become disengaged from the consultation, confused, upset or angry.

Responsiveness to the patient is a composite skill, and includes careful listening, an interest in the presenting problem, and a willingness to follow where the patient leads. It is an important counterbalance to the global skill ‘Structures consultation’, as a consultation without any structure will feel chaotic and out of control whereas a consultation without responsiveness will feel regimented and insensitive to the patient.

Being responsive to the patient is harder in audio consultations than face-to-face consultations. Problems with the audio link may make interrupting the patient more frequent, and it is harder to detect confusion or disengagement or frustration within the consultation. It is also harder to demonstrate empathy over an audio link. It is therefore important to speak clearly and slowly, and check that the patient is happy with the consultation and with the advice being offered.

Activity 1

Review several of your video consultations initially on your own and then with your trainer or experienced colleague. Do you think you have listened enough to your patients? In particular, consider:

• Do you interrupt patients?
• Do you allow patients to finish explaining their concern or preferences?
• Do you sensitively explore cues?
• Do you let the patient know that they have been heard and understood?

Do you use ICE and information obtained from cues to guide discussion with the patient? Are there signs that the patient is becoming disengaged, confused or even upset or angry?

Activity 2

Now apply the results of ‘Activity 1’ to future consultations. As with other activities, try to improve one skill at a time. For example, if you discover that you frequently interrupt the patient, then focus entirely on completing consultations without interrupting. How does this alter the effectiveness of the consultation?

Activity 3

Once you are sure that you have made significant changes in responding to the patient, watch a couple of consultation videos with your trainer. Ask the trainer whether the changes have improved your responsiveness, and whether this has altered the effectiveness of the consultation?

Audio activity 1

Review several of your audio consultations and ask the same questions that you ask in Activity 1 above. How do you compare in terms of responsiveness in audio v face-to-face consultations? What could you do differently in the audio setting to improve this?

Exercise 1

If you are adopting a lot of behaviours that indicate that you realise are not responsive to the patient, ask why this is happening? Possibilities include:

Exercise 2

Ask yourself why you are short of time/lacking in confidence etc. What can you do to make your consultations less pressured?

• lack of time
• lack of interest in the problem that the patient is bringing
• lack of confidence/knowledge in managing a particular problem
• lack of knowledge
• stress