Chapter 3: Consulting skills

The objectives of the consultation are to:

• determine the exact reason for the presentation

• achieve a good therapeutic outcome for the patient

• develop a strong doctor–patient relationship

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 interviewing skills, clinical skills, diagnostic skills, management skills, communication skills, educative skills, therapeutic skills, manual skills and counselling skills.

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).

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.

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:

1. 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

2. To consider other issues:

   • continuing problems

   • risk factors

3. To choose, with the patient, an appropriate action for each problem

4. To achieve a shared understanding of the problems with the patient

5. To involve the patient in the management and encourage him or her to accept appropriate responsibility

6. To use time and resources efficiently and appropriately:

   • in the consultation

   • in the long term

7. To establish or maintain a relationship with the patient that helps to achieve the other tasks

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.

The consultation can be considered in three phases, as follows:

1. Establishment of rapport (see FIG. 3.1)

2. Diagnostic phase

   • the interview and history

   • the physical and mental examination

   • investigations

3. Management phase

   • explanation and education

   • prescribing medication

   • procedural–therapeutic or extended diagnostic

   • referral

   • follow-up

The doctor has four basic tasks to perform during the history-taking phase of the consultation. These are to determine:

1. the patient’s stated reason for attending

2. why the patient is attending today, or at this particular time in the course of this illness

3. a list of problems or supplementary symptoms

4. any other initially unspoken or hidden reason for attending (e.g. the fear of cancer)

The old medical cliché that ‘a good history is the basis of the clinical examination’ is as relevant as always. The art of history taking, which is based on good communication, is the most fundamental skill in general practice and requires a disciplined approach.

A very good approach is that used by Professor Rita Charon of Columbia University: ‘I’m going to be your doctor, so I need to know a great deal about your body, health and life. Please tell me what you think I should know about yourself and your situation.’

Guidelines include:³

• Commence by eliciting the presenting complaint.

• Permit an uninterrupted history.

• Use appropriate language—keep the questions simple.

• Use specific questions to clarify the presenting complaint.

• Write notes or use the keyboard to record information but maintain as much eye contact as possible.

• Enquire about general symptoms, such as fatigue, weight changes, fever, headache, sleep and coping ability (see TABLE 3.2). These are important since they uncover ‘red flags’ for serious, life-threatening disorders.

• Undertake a relevant systems review.

• A historical checklist includes past medical history, complete medication history, drug habits and sensitivities, family history, psychosocial history and preventive care history.

• Give feedback to the patient about your understanding of the problems and agenda, and correct any misconceptions.

Good questions

In order to determine any underlying agenda or significant psychosocial problems, it is very helpful to use analytical questions. Such opening questions and inviting statements could include:

• Why have you come to see me today?

• Do you have any particular concern about your health?

• That really interests me—tell me more—it seems important.

• What were you hoping I could do for you today?

• Where would you put your real feelings between 0 and 100%?

• What is it that’s really upsetting or bothering you?

• What do you really think deep down is the cause of your problem?

• Are you basically satisfied with your life?

• Is there anything that I haven’t asked you and that you should tell me about?

• Tell me about things at home.

• Tell me about things at work.

• Do you experience any bullying?

• Are you afraid that something bad is going to happen to you?

• Is your relationship with any particular loved one/person causing you stress? (This may lead to information about sensitive issues such as domestic violence or sexual problems.)

• Is there anything in your life that you would like to change?

• I’m concerned about what you are not telling me.

Basic interviewing techniques

A number of basic interviewing techniques⁴ encourage communication. It is important to use the least controlling interview techniques before embarking on direct questioning.

Questions

When the patient is asked a question, the doctor tends to take control of the interview, and so directs it along the lines of his or her own thinking or hypothesis generation. The problem is that if questions are used too early in the interview, the amount of desirable information is restricted and may disrupt the true priorities of the patient’s concerns.

Open-ended questions and direct questions are very useful at appropriate times, while other questions are very restrictive. Examples, using pain as the ‘problem’, are:

• Open-ended question: ‘Tell me about the pain.’

• Direct question: ‘Where is the pain?’

• Closed question: ‘Is the pain severe?’

• Leading question: ‘The pain is severe?’

• Reflective question: ‘You want to know the cause of the pain?’

The open-ended question

The open-ended question is essential in initiating the interview. A question such as ‘What kind of troubles have you been having?’ says to the patient ‘I’m interested in anything you may feel is important enough for you to tell me’.

The open-ended question gives the patient an opportunity to take temporary control of the consultation and to outline problems and concerns.

Ongoing interview strategies of listening and silence, facilitation and summarisation are outlined in CHAPTER 4, (section on Communication in the consultation).

Information from other sources

Sometimes it is important to obtain information from other sources, especially friends or relatives. Off-hand comments from others may be loaded with ‘cues’ and one should be listening intently.

Problem definition

Part of the diagnostic process is defining the patient’s problem or problems. The more complex the presentation, the more necessary it is to have an orderly approach. It is clearly important to list the problems in a priority order. These problems may have been ‘offered’ by the patient, ‘observed’ by the doctor, ‘derived’ during the interview or ‘known’ from the past history. Problems can be conveniently considered as organic or physiological, and intrapersonal or social.⁵

Touching the patient

Sometimes a natural response is to touch the distressed patient as a reassuring gesture. It is best to adopt a caring-and-support gesture, such as offering tissues to the weeping patient, but it may be quite acceptable for most patients to give a reassuring, momentary touch somewhere between the shoulder and wrist on the arm nearest to you. Touching should be a natural gesture that is comfortable for both the doctor and patient. Touch elsewhere should generally be avoided.

If a diagnostic hypothesis based on the history is being tested, the examination may be confined to one system or to one anatomical region. However, other regions, systems or a general examination may be undertaken for medicolegal or preventive reasons. Patients tend to feel vulnerable during the physical examination, so their sensitivity and modesty have to be respected. Generally, the examination is conducted in relative silence, with the doctor instructing the patient what to do.

Patients need to be warned of possible discomfort or pain that may accompany certain examinations, of the reason for the examination, and of its immediate results, particularly if normal. Continued silence on the doctor’s part is often interpreted by patients as being indicative of something serious or unusual being found. For the same reason the doctor’s non-verbal behaviour is important.

The following guidelines have been recommended by the NSW Medical Board for consultations and physical examinations:

• Carefully explain the nature and purpose of the physical examination before you start. Take particular care with explanations before rectal, vaginal, breast and genital examination.

• Indicate when an examination may be uncomfortable and ask the patient to advise if you are causing pain.

• If a patient is required to disrobe, explain to what extent undressing is required and why.

• A patient’s modesty should be preserved when undressing and dressing before and after a physical examination. Privacy screens, sheets and gowns should be provided as a matter of course. Clinic staff should not interrupt physical examinations.

• If the patient requests the presence of a chaperone or a friend, this should be respected.

• Do not lock the door of the consultation room. The setting should allow the patient confidence to terminate the consultation at any time if he or she is uncomfortable.

• Ask yourself ‘Is what I am doing part of accepted medical practice?’.⁸

It is often necessary to arrange for special tests to assist in the diagnostic process or to monitor the progress of certain illnesses or response to treatment. The informed consent of patients must be obtained. A collaborative decision for or against certain tests may be negotiated.

GPs have a responsibility (clinical and economic) to be very discerning and selective in the investigations that they choose. The questions that should be asked in decision making include:

• Is this investigation necessary?

• Will it change my management?

Richard Asher (1954) listed the questions a clinician should ask before requesting an investigation:⁹

• Why am I ordering this test?

• What am I going to look for in the result?

• If I find it, will it affect my diagnosis?

• How will this affect my management of the case?

• Will this ultimately benefit the patient?

In general, investigations should be performed only when the following criteria are satisfied:⁹

• The consequence of the result of the investigation could not be obtained by a cheaper, less intrusive method (e.g. taking a better history or using time).

• The risks of the investigation should relate to the value of the information likely to be gained.

• The result will directly assist in the diagnosis or have an effect on subsequent management.

The management phase of the consultation may immediately follow the information-gathering interview, or it may take place on review, after diagnostic tests or referral. It should be remembered that there are at least two people concerned in management: the doctor and the patient. Poor patient compliance with any proposed therapy can be a result of a poorly conducted management phase. It is necessary not only for the doctor to make statements concerning therapy and the reasons for the chosen therapy, but also for the information to be conveyed in a language appropriate to each patient’s understanding. Negotiate a management plan.

Management includes immediate care, prevention and long-term care. Doctors generally tend to be authoritarian in their management proposals. Whole-person management, however, implies that the patient’s views are listened to, explanations are offered where necessary by the doctor, and an educative approach is adopted to encourage the patient to actively participate in management and preventive behaviour, where possible.

The objectives of the management phase of the consultation are summarised in TABLE 3.3.

The sequence of the management interview⁴

The following, which represents an excellent teaching strategy, is a suggested 10-point plan or sequence for conducting a management interview. These guidelines will not always need to be applied in their entirety, and may need to be staged over a number of consultations. The use of this sequence should ensure identification of all the patient’s problems by the doctor (including fears, feelings and expectations), adequate patient understanding of his or her problems, an acceptable and appropriate treatment plan being defined for each problem, preventive opportunities being addressed, and the patient being satisfied with the consultation and being clear about follow-up arrangements.

The sequence is as follows.

1. Tell the patient the diagnosis

2. Establish the patient’s knowledge of the diagnosis

3. Establish the patient’s attitude to the diagnosis and management

4. Educate the patient about diagnosis

   • Correct any incorrect health beliefs recognised in point 2.

   • Supplement the patient’s existing knowledge to a level appropriate to the needs of the patient and the doctor.

5. Develop a management plan for the presenting problem

   Develop precise instructions using three headings:

   • Immediate: always included, even if no action is proposed

   • Long term: for chronic, long-term or recurrent illnesses

   • Preventive: sometimes specific measures apply—often patient education is the method required

   The patient should be encouraged at this stage to participate in decision making regarding management and to make a commitment to the plans.

6. Explore other preventive opportunities

7. Reinforce the information

   • Use the patient’s own results (e.g. X-rays and ECGs).

   • Encourage the patient to participate in the decision making and in accepting some degree of responsibility for his or her own management.

8. Provide take-away information

   Examples of this important strategy include patient instruction leaflets and resource contacts.

9. Evaluate the consultation

10. Arrange follow-up

Closing the session

Good closure is an important strategy; ask ‘Has this visit helped you and your problems—is there anything more I can do?’

A patient management strategy

Brian McAvoy, writing in Fraser’s excellent book Clinical Method: A General Practice Approach, presents a helpful aide-mémoire in the approach to patient management:⁹

1. reassurance and/or explanation

2. advice

3. prescription

4. referral

5. investigation

6. observation (follow-up)

7. prevention

Prescriptions

It is worth emphasising that prescribing medicine is a relatively complex skill that requires considerable knowledge of the disease, patient’s expectations, the drugs prescribed, their interactions and their adverse reactions. Part of this skill is making a decision not to prescribe medication when it is not absolutely necessary and then explaining the reasons and including non-pharmacological measures. This decision may be made in the context of a patient expecting a biochemical solution for his or her problem. As McAvoy points out, ‘If in doubt whether or not to give a drug—don’t’.⁹

Rational prescribing applies particularly to opioids, antibiotics and tranquillisers.

General guidelines for antibiotic prescribing

Choose the agent with the:

• narrowest spectrum that will cover the likely pathogens (based on culture/sensitivity)

• lowest cost if efficacy and safety are otherwise equal

• fewest serious side-effects

• duration as short as possible

Avoid wherever possible:

• prescribing antibacterial antibiotics for viral respiratory infections

• combinations if a single drug is likely to be effective

• topical antibiotics, as resistance is much more likely to develop (exceptions include eye infections and vaginitis)

• antibiotic combinations, except in proven clinical circumstances or when coverage is difficult with a single drug

• prophylactic antibiotics, unless they are of proven benefit (in general only in some elective surgery or dental procedures)

The common respiratory infections such as acute otitis media, pharyngitis, tonsillitis, acute bronchitis, bronchiolitis and influenza have commonly a viral cause and it is appropriate to treat symptomatically with a ‘wait and see’ surveillance.¹⁰

Referral

The decision to refer a patient is also another important skill. It is often difficult to find the right balance. Some practitioners refer excessively—others cling to their patients inappropriately. It is a mistake not to refer a patient with a serious chronic or life-threatening disease. Apart from consultants and hospitals, referral should be considered to GP colleagues or partners with special interests or expertise, support groups and other members of the primary health care team, such as physiotherapists, dietitians, chiropodists and social workers. At all times the GP should act as the focal reference point and maintain control of patient management.

The ‘gatekeeper’ role of the GP

A patient’s GP is the obvious and ideal linchpin in the health care system to take responsibility for the patient’s health concerns and management. The patient may become confused with the system, especially if his or her problems are many and complex. The patient’s GP has a vital role in acting as a ‘gatekeeper’ between primary and secondary care, and between paramedical services. The GP should always act in the patient’s best interests and intervene, if necessary, to ensure that the patient is getting the best possible care.

The healing art of the doctor

The counselling process in general practice is based on the therapeutic effect of the doctor. This well-recorded feature is reinforced if the doctor has a certain professional charisma, and is caring and competent. We cannot underestimate the dependency of our patients on this healing factor, especially where significant psychic factors are involved.