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The essential unit of medical practice is the occasion when in the intimacy of the consulting room the person who is ill or believes himself (or herself) to be ill, seeks the advice of a doctor whom he (she) trusts. This is the consultation and all else in the practice of medicine derives from it.
Sir James Spence 1960
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The objectives of the consultation are to:
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determine the exact reason for the presentation
achieve a good therapeutic outcome for the patient
develop a strong doctor–patient relationship
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The skills of general practice
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A successful outcome to the medical consultation depends on a whole array of skills required by the GP. Although interrelated, these skills, which can be collectively termed ‘consulting skills', include clinical skills, diagnostic skills, management skills, communication skills, educative skills, therapeutic skills, manual skills and counselling skills.
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Communication skills, which are fundamental to consulting skills, are the key to the effectiveness of the doctor as a professional, and expertise with these skills is fundamental to the doctor–patient relationship. Communication skills are essential in obtaining a good history and constitute one of the cornerstones of therapy (see CHAPTER 4).
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A skilled interviewer will succeed in transmitting his or her findings to the patient so that they are clearly understood, are not unduly disturbing, and inspire trust and confidence in the physician.
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Models of the consultation
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Several models that formalise the general practice consultation can be very useful for developing an understanding of the process of the consultation. Two classic models are those by Pendleton and colleagues,1 and by Stott and Davis.2 Pendleton and colleagues, in their landmark book The Consultation: An Approach to Learning and Teaching,1 defined seven key tasks to the consultation, which serve as helpful guidelines:
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To define the reason for the patient's attendance, including:
the nature and history of problems
their aetiology
the patient's ideas, concerns and expectations
the effect of the problems
To consider other issues:
continuing problems
risk factors
To choose, with the patient, an appropriate action for each problem
To achieve a shared understanding of the problems with the patient
To involve the patient in the management and encourage him or her to accept appropriate responsibility
To use time and resources efficiently and appropriately:
in the consultation
in the long term
To establish or maintain a relationship with the patient that helps to achieve the other tasks
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The exceptional potential in each primary care consultation described by Stott and Davis,2 which is presented in Table 3.1, also acts as an excellent aide-memoire to achieve maximal benefit from the consultation.
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