Sophie Cook: The pitfalls of consultation skills models

sophieHave GPs become too pre-occupied with consultation skills models? According to Roger Neighbour, author of “The inner consultation” a book familiar to most generations of GPs, while consultation models are a helpful guide, the key to being a good consulter lies not only in the technique of the consultation, but in the ability to listen and respond to our patients.

Roger Neighbour delivered a thought provoking keynote speech at the RCGP annual conference yesterday, which kicked off with a pre-conference session for associates in training (AITs) and GPs in their first five years post qualification (First 5s). He highlighted some of the changes in general practice that have emerged over recent years, which now make consultations more challenging than ever. Time pressures, Qof targets, the need to keep up to date with endless guidelines or protocols, a new breed of highly knowledgeable consumers, and an older patient population with more comorbidities give GPs a tough time. When Roger Neighbour asked the young audience to raise their hands if they found general practice leisurely and contemplative, there was a notable absence of activity.

We live in a dynamic medical world where technology is rapidly evolving, new treatments continue to come to market and approaches to disease management are often revised. These ongoing stresses for busy GPs present potential obstacles to the doctor patient relationship. GPs now have their own agenda as well as the patient’s to fulfil, and all this must be achieved in 10 minutes. It’s a tall order.

To qualify as a GP in the UK nowadays, trainees must demonstrate not only sound medical knowledge, but also appropriate communication skills. The Clinical Skills Assessment (CSA) demands good communication skills. GP trainees will be familiar with the works of Pendleton, Calgary Cambridge, and Roger Neighbour to name but a few, who provide helpful consultation skills models to frame consultations and get trainees through the CSA.

However, yesterday Roger Neighbour reminded us that rigid use of these models in practice can lead to consultations that are prescriptive and formulaic at the expense of individual style and flare. Perhaps it’s time to go back to basics. Roger Neighbour explained how a consultation is really about a patient who has a story to tell. He reminded us that in its simplest form, the consultation is where an exchange of stories takes place and where a patient and doctor share their ideas about the problem at hand. He emphasised the importance of listening and allowing patients to tell their story while reassuring them that they have your attention. Summarising the problem is also important and allowing the patient to hear your thoughts is helpful. Based on these principles, Roger Neighbour says there are four simple rules to get through a consultation; pay attention, give receipts, summarise, and think aloud.

Stripping the consultation back like this is a refreshing thought and might remove some of the threat of communication skills for doctors who have struggled to find a model that works for them. In those precious 10 minutes, time spent listening might seem time wasted, but early investment in the patient’s agenda can be time saving in the long run. With a busy surgery, targets to meet, and growing paperwork demands, it’s easy lose sight of the task at hand and to forget to listen. Patients’ priorities must be our priority. If we keep this focus rather than trying to squeeze each consultation into a particular model, perhaps this might help consulations to be more flexible.

Sophie Cook is clinical reviews editor, BMJ.