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Consultation Skills

Consultation Time, Length and Structure

Sometimes, GPs over run, and that's okay.

In the CSA, you have 10 minutes to do a GP consultation and a lot of trainees think this is unfair especially as in normal surgeries, a lot of qualified GPs and indeed their trainers run over time!   The thing is, in the CSA, you do not have to write up notes, most of the information is presented to you in a condensed way and you don’t have to spend time searching the records.  In addition, the cases are selected to last less than 10 minutes but in real life, they are not!   So, it is kind of fair that you are given 10 minutes per CSA consultation – all of them have been practised and deemed doable within 10 mins by the CSA examiners.    

In real life, you will hopefully vary the time you give patients.  For example, I always run over on my surgeries by about 20 minutes.   And I accept that.   Some patients I give 10 minutes to, others like the depressed patient requires more, yet others need less (coughs and colds).   But the thing is, on the whole, I do not spend 20 minutes on coughs and colds and i do not spend 45 minutes on every one of my patients who are depressed.   Yes, I might over run, but only by a bit.  

If you’re running over by an hour or more on every surgery, then that may well be an indication that there is a problem with the either your time management or structure in the consultation.   Talk to your trainer about this.   Like I said, most GPs over run by about 10-20 mins per surgery.  

Why trainees run out of time

Trainees run out of time either because they are not managing their time in the consultation or because the structure of their consultation is poor.   In fact, both are so closely linked that I am going to talk about the two together.

How to tackle poor structure (and thus time)

If you have a poor consultation structure, you will never exactly be driving the consultation.  Instead, you will be flowing with the consultation until it just fizzles out.  Some will fizzle out in 10 minutes but others can take 20-30-40 minutes or more.    So, if you had a better structure, you would know exactly where to head next and how long you should spend on each section.   By having a good structure not only means you cover things methodically but also in a timely way.    It’s a bit like travelling from Leeds to Birmingham.   Would you rather I just stuck you somewhere in Leeds and ask you to make your own way to Birmingham by following the signs you come across.  Or would you prefer to look at a map and a list of exact directions?    Which would you feel more comfortable with?  Which would ensure you get to Birmigham in a timely manner without getting lost?   Can you see how having a consultation structure is a bit like having a map and directions list.  Can you see how easier it would make life both in terms of covering things comprehensively and in a timely way?

Another analogy for you – if you don’t have a consultation framework, then basically it’s a bit like a train on no tracks – it can go in all sorts of directions and end up anywhere.   The train can end up going around and around and around until it comes to a stop somewhere.  Likewise, doing a consultation by just jumping in without a framework is likely to result in 

  1. a higgledy piggledy unstructured chaotic consultation that
  2. eats up a lot of time and 
  3. which is unpredictable and therefore
  4. may or MAY NOT end up somewhere useful.
  5. Do you really want to leave things to chance or do you want to be more in control and more certain that your outcomes are going to be helpful?   If you do, then use one of the consultation frameworks in the ‘WEBLINKS’ section above.   Play with a few and tweak them to formulate your own.

  • Determine what you are going to try and achieve in the first 5 minutes (I suggest Screening, Agenda Aetting and Data Gathering including clinical examination).
  • Determine what you are going to try and achieve in the second 5 minutes (I suggest Explanation, Management and Follow Up).
  • Remember to cognitively keep an eye on the time at first.   You have to build the skill of doing things in an efficient and timely way.    You will not learn this if you don’t exert a little time pressure on yourself.   And eventually, you will develop your own techniques for “speeding things up” and become more efficient.  You will also learn the art of recognising and asking questions that will make a difference versus those that don’t.

Ram's 6S's for Structure

A structured consultation is important because in an unstructured consultation – not only do you end up eating lots of time, but you will miss asking important clinical things.   These are the 6 consultation microskills that I believe help with adding structure to the consultation.

  1. Screening – screen and find out exactly what yours and the patient’s agenda are.  Explore ONE problem at a time.  
  2. Set the agenda – then agree what will be covered and what will be deferred for another time. Explore ONE problem at a time.  Don’t jump between them back and forth repeatedly!
  3. Signpost – when you want to talk about a particular area of the consultation.   Signpost also when you have finished an area and want to move onto something else  e.g.  To move from open patient centred  to closed doctor medical ‘red flag’ questions: “Okay, thanks for telling me what’s been troubling you.  Can I now ask you some specific questions to help me work out what is going on?”
  4. Sequencing – Structure the consultation in logical sequence.  For example, if there is a single problem, go through the data gathering methodically.   If there are 2 or more problems, trainees often flit between the problems and this makes the consultation unstructured and DANGEROUS.  So, stick to one clinical problem at a time and explore it methodically (i.e. in sequence).  Work out what came first, what happened next, and then what and so on.  
  5. Summarise periodically.  This helps to close off a line of enquiry and helps you move on.  It also reminds you what you have covered and yet to cover.     “Okay, so what you’re saying is that your headaches started a month ago and don’t seem to be settling and you’re now worried because you’re getting double vision.    (patient nods).  Okay, so can we now move on to examining you please?”
  6. Use Silence effectively – Using natural pauses and letting things sink in (rather than interrupting and filling in space with words) makes a conversation less overloaded and more structured as the spaces separate out the different parts of the consultation.
  • Dr: So your headaches, tell me more about those.
  • Pt: Well they’ve been going for for 4 weeks now and they are really troublesome.
  • Dr: Whereabouts are they?
  • Pt: Over here doctor (patient points to frontal area)
  • Dr: And whats the pain like?
  • Pt: It’s excruciating doctor.   
  • Dr: So, it’s more sharp than dull, heavy or tight?
  • Pt: No, I’d probably say more tight.
  • Dr: And does the light hurt your eyes?
  • Pt: Yeah, a little bit.  yellow light particularly.
  • Dr: Why yellow light?   (NOT A HELPFUL QUESTION)
  • Pt: I don’t know.   I was dancing the other day at a friend’s party and the yellow light from the dancing strobe I think affected me more than the others I think.
  • Dr: How unsual.   
  • Pt: Yes I thought so too. 
  • Dr: Do any other colours affect your eyes?   (DOCTOR GOES OFF AT A TANGENT AT THE EXPENSE OF OTHER MORE IMPORTANT CLINICAL QUESTIONS)
  • Pt: Sometimes white or blue does too.
  • Dr: In the same way as the yellow light?     
  • Pt: Well, not as bad I suppose.  Just a twinge.
  • Dr: And did anyone else find those lights painful?  (UNHELPFUL QUESTION)
  • Pt: I don’t know really.  I didn’t ask anyone.
  • Dr: And were you wearing glasses at the time?  (UNHELPFUL QUESTION)
  • Pt: No, I don’t wear glasses.
  • Dr: How odd!   (WASTING TIME)
  • Pt: Yeah I thought so too.  That’s why I thought I’d mention it.  It’s not serious is it doctor?  Oh, I’m all worried now.
  • Dr: So your headaches, tell me more about those.
  • Pt: Well they’ve been going for for 4 weeks now and they are really troublesome.
  • Dr: Whereabouts are they?
  • Pt: Over here doctor (patient points to frontal area)
  • Dr: And whats the pain like?
  • Pt: It’s excruciating doctor.   
  • Dr: So, it’s more sharp than dull, heavy or tight?
  • Pt: No, I’d probably say more tight.
  • Dr: And does the light hurt your eyes?
  • Pt: Yeah, a little bit.  yellow light particularly.
  • Dr: So is it so bad you have to wear dark glasses or go shut your eyes and lie down?   (A MUCH MORE HELPFUL QUESTION)
  • Pt: Oh no, nothing like that doctor. 
  • Dr: Ok, that’s good.  So back to the questions, have you had any vomiting?
  • Pt: No
  • Dr: Double vision?    (MORE IMPORTANT CLINICAL QUESTIONS)
  • Pt: No
  • Dr: Fits, faints or funny turns?
  • Pt: Ermm…again, no
  • Dr: And what about your sleep, do you actually wake from your sleep because of the headache?
  • Pt: No
  • Dr: And from your records, I see there is no serious illnesses you’ve had like cancer or anything.  Is that right?
  • Pt: Yeah, I’m pretty well really.  
  • Dr: And finally, is it affected by your posture, like when you’re bending or anything?
  • Pt: Nope.
  • ALL RED FLAGS COVERED

More on the first 5 minutes of the consultation

There are two main things (other than developing rapport) that you need to achieve in the first 5 minutes of any consultation.

  1. Set the agenda
  2. Data gathering (= gathering information).

Setting the agenda is important if a patient comes in with a lot of problems.  You need to be able to work out which one to focus on first.    Sometimes the doctor will have to suggest what to look at first (particularly if there is something medically important that must be dealt with today eg chest pains).   But other times, it can be the patient that guides you.    Where trainees fall down is in spending too long the agenda setting   OR not truly doing any form of agenda setting.  The problem with not doing any form of agenda setting is that if the patient has two or more problems, you then end up mixing them up and your history taking will become messy as you start flitting between the two (or more problems).  In fact, this flitting between several agendas is dangerous because if you flit back and forth between multiple presenting complaints, YOU WILL overlook things and miss important questions to ask.   So, my advise to you is to set the agenda in a pretty slick and quick way.    Then move onto the data gathering.

The data gathering is another area trainees lose a lot of time.   Why?  Because they end up asking questions that aren’t important at the expense of the essential ones.   Look at these two dialogues to illustrate my point…

  • Dr: So your headaches, tell me more about those.
  • Pt: Well they’ve been going for for 4 weeks now and they are really troublesome.
  • Dr: Whereabouts are they?
  • Pt: Over here doctor (patient points to frontal area)
  • Dr: And whats the pain like?
  • Pt: It’s excruciating doctor.   
  • Dr: So, it’s more sharp than dull, heavy or tight?
  • Pt: No, I’d probably say more tight.
  • Dr: And does the light hurt your eyes?
  • Pt: Yeah, a little bit.  yellow light particularly.
  • Dr: Why yellow light?   (NOT A HELPFUL QUESTION)
  • Pt: I don’t know.   I was dancing the other day at a friend’s party and the yellow light from the dancing strobe I think affected me more than the others I think.
  • Dr: How unsual.   
  • Pt: Yes I thought so too. 
  • Dr: Do any other colours affect your eyes?   (DOCTOR GOES OFF AT A TANGENT AT THE EXPENSE OF OTHER MORE IMPORTANT CLINICAL QUESTIONS)
  • Pt: Sometimes white or blue does too.
  • Dr: In the same way as the yellow light?     
  • Pt: Well, not as bad I suppose.  Just a twinge.
  • Dr: And did anyone else find those lights painful?  (UNHELPFUL QUESTION)
  • Pt: I don’t know really.  I didn’t ask anyone.
  • Dr: And were you wearing glasses at the time?  (UNHELPFUL QUESTION)
  • Pt: No, I don’t wear glasses.
  • Dr: How odd!   (WASTING TIME)
  • Pt: Yeah I thought so too.  That’s why I thought I’d mention it.  It’s not serious is it doctor?  Oh, I’m all worried now.
  • Dr: So your headaches, tell me more about those.
  • Pt: Well they’ve been going for for 4 weeks now and they are really troublesome.
  • Dr: Whereabouts are they?
  • Pt: Over here doctor (patient points to frontal area)
  • Dr: And whats the pain like?
  • Pt: It’s excruciating doctor.   
  • Dr: So, it’s more sharp than dull, heavy or tight?
  • Pt: No, I’d probably say more tight.
  • Dr: And does the light hurt your eyes?
  • Pt: Yeah, a little bit.  yellow light particularly.
  • Dr: So is it so bad you have to wear dark glasses or go shut your eyes and lie down?   (A MUCH MORE HELPFUL QUESTION)
  • Pt: Oh no, nothing like that doctor. 
  • Dr: Ok, that’s good.  So back to the questions, have you had any vomiting?
  • Pt: No
  • Dr: Double vision?    (MORE IMPORTANT CLINICAL QUESTIONS)
  • Pt: No
  • Dr: Fits, faints or funny turns?
  • Pt: Ermm…again, no
  • Dr: And what about your sleep, do you actually wake from your sleep because of the headache?
  • Pt: No
  • Dr: And from your records, I see there is no serious illnesses you’ve had like cancer or anything.  Is that right?
  • Pt: Yeah, I’m pretty well really.  
  • Dr: And finally, is it affected by your posture, like when you’re bending or anything?
  • Pt: Nope.
  • ALL RED FLAGS COVERED

At the end of the day, you must know which questions are important to ask for common presenting complaints like back pain, headaches, tiredness all the time and so on.   In addition, you must know your red flags for each clinical system area. This will ensure you take a safe enough history.      It’s unforgivable to do an incomplete red flag enquiry.  You must ask the relevant ‘red flag data set’.

And don’t forget to signpost.  Say something like “Okay, I’d now like to spend a few moments asking you some important medical questions to help me work out what is going on.  Is that okay?”.   Signposting will help mark to both you and the patient that the next phase of the consultation is purely focused on asking those important medically questions and should (hopefully) stop either of you from veering off.  If the patient interrupts with something irrelevant or goes off at a tangent, please bring them back rather than follow them through.   Say something like “Okay, don’t worry, we’ll talk about your foot in a moment, but can we come back to these important medical questions that I need to ask you about your chest pains?”.

So, in summary, my advise would be…

  1. Know the important questions for common presenting complaints
  2. Know the ‘Red Flags for the CSA’ document like the back of your hand.  And get those questions out of the way…. document available in the QUICK LINKS section above.
  3. Signpost that you are going to ask some specific medical questions.  
  4. And ask the questions swiftly and quickly.

More on the last 5 minutes

Where trainees go wrong in the last 5 minutes of the consultation is spending way too long on an explanation.  Either that or they end up explaining things in such a complex convoluted way that it confuses the patient and the patient then asks more and more questions to clarify, when then eats up all the time.

So, in summary,

  1. Your explanation should be nice and simple.  Short and sweet.
  2. Avoid jargon.   Use everyday English.
  3. Relate it to the patient’s framework where possible,
  4. Use analogies if you can.   https://www.bradfordvts.co.uk/consultation-skills/medical-analogies/
  5. Quickly move onto the management plan.

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