Consultation Skills
Data Gathering and Diagnosis
Introduction: Starting the consultation
Everyone introduces themselves slightly differently, everyone will have their own style. It's usually advisable to introduce yourself as Dr (surname) or Dr (forename, surname) rather than just on a first-name basis.
Make sure within this stage of the consultation you start with your open question, listening hard for any cues that are mentioned. We found in the previous CSA exam, that EVERY SINGLE case presented us with one cue early on within consultation.
Be sure to establish at this stage what they are presenting with, and if there are any other problems they wish to discuss today.
Tips for the beginning of the consultation: Don’t go too soon into closed questions. Try to keep your questions open as long as you can.
For example this would be how some Doctors may choose to start a consultation:
Doctor: Hello, what’s brought you in today
Patient: Well i’ve started with this really bad pain in my stomach, and it’s making feel a little nauseous.
Doctor: how long ago did the pain start?
In the above example, the Doctor has closed down the consultation far too early. A far better example would be:
Doctor: Hello, what’s brought you in today
Patient: Well i’ve started with this really bad pain in my stomach, and it’s making feel a little nauseous.
Doctor: How did the pain start?
The second question from the doctor is now much more open and allows the patient an opportunity to reply with far more detail and freedom.
Consultation Models: Putting Theory into Practice
No doubt you will remember revising for your AKT, and learning about the different consultation models. Well, now is your chance to apply them! There are a large number of consultation models out there, with the Calgary Cambridge method being a good starting point.
The Calgary Cambridge method. Derived from Pendleton's approach it is an evidence-based approach to integrating 'tasks' of the consultation for effective communication.
The consultation is divided into:
Initiating the session (rapport, reasons for consulting, establishing agenda).
Gathering information (patient's story, open and closed questions, identifying cues).
Building the relationship (developing rapport, accepting patient's views/ feelings, demonstrating empathy and support).
Explanation and planning (giving digestible information and explanations).
Closing the session (summarising and clarifying the agreed plan).
'The Inner Consultation' by Roger Neighbour
five-stage model:
'Connecting'
'Summarising'
'Handing over' (sharing with the patient an agreed management plan which hands back control to the patient.)
'Safety-netting'
'Housekeeping'
We found that adding in a few elements from Roger Neighbour's Inner Consultation method, helped to make a good basis for a consultation:
Initiating the session
Gathering Information
Building the relationship / connecting
Handing Over
Explanation and planning / Safety-netting
Closing the session / Housekeeping.
The latter point here - housekeeping - is very important in the SCA. As you will get some cases that throw you, that may make you think, that you may even do badly in. When this happens, you need a tried and tested method of moving on. Otherwise, preoccupation with a previous case will only harm your chances to do well on the next ones.
EssentialGPTrainingBook has a great document highlighting different consultation models, and how to apply them, click here to read it
History Taking: The Structured Approach
It's important to have a structure for your history taking. We found this structure worked well:
Presenting complaint
*Cue Handling*
History of presenting complaint
Past medical history
Medication history / allergies
Family history
Social history ( smoking, alcohol, illicit drugs, occupation & driving ), including the new important heading of “psychosocial context”. More info on this can be found here
**Ideas, concerns and expectations**
***Assessing impact on quality of life***
Remembering that layout means you shouldn't forget to ask anything important.
New for the SCA is the following marking criteria:
“Makes effective use of existing information about the problem and the wider context.”
We know that before every case, you get 3 minutes to read the patient summary. The RCGP will now include far more information in the medical summary than they used to in previous exams. This will often include previous consultations, investigation results and examination findings from other health professionals. It is really important that you read through this carefully. Retaining and utilising this information is the key to running a smooth, efficient consultation.
Cue Handling: Unlocking the Consultation
Cues are probably the most important aspect to get right in the SCA. Whilst the above framework for history taking is a solid basis, it's not really possible to follow it rigidly in most cases.
One important point, there are no dead end cues: If a patient mentions a cue, it will be there for a reason. Remember that the cases you undertake in the SCA will have been practised and perfected that morning before you arrive. Any cue presented to you is a cue you must follow!
We found that within the presenting complaint, every case had a cue that you needed to deal with. So the next question, is how do you deal with these cues.
There are two ways, the first is that you can park that cue:
"I noticed you've mentioned ..... I would like to come back to this later if this is ok?"
The second way is to deal with the cue there and then.
"I noticed you've mentioned ..... Tell me more about this.."
There is no right or wrong way to handle cues (with the obvious exception of ignoring them!). We found that following the cues when they first presented was the easiest method for us, as this often exposed the patient’s ideas, concerns, and expectations very quickly. Once you have followed the cue as far as it went, then you go back to the above framework to fill in any details you haven't yet got. If you do decide to park the cue, then remember to come back to it later!
No: Means No
This bit of advice is short and simple: No, means no! If you ask a patient something that is a dead-end or enquire further about something you feel is a cue but isn't, the patient will 'help' you by pointing out that there is nothing further to discuss in this area. This is usually done in a fairly unambiguous way.
Do not then continue to waste your time trying to go down the same route of inquiry, it will get you nowhere, and it will waste your precious time.
Examinations: Not required
The RCGP has confirmed that the SCA will not be an exam that tests your examination knowledge. These will now be tested through your WBPA on your e-portfolio. Any relevant examination findings will usually either be given by the patient themselves (home BP readings, sats readings, temperature probes at home etc…) or will be presented to you in the summary of the case before the case begins. This may be in the form of an examination done by your colleague, or other health professionals. There may still be cases where you need to book a face-to-face appointment to bring the patient down for further examinations, but you will no longer need to examine the patient within the cases in your exam.
