Consultation skills: are yours up to scratch?

In the first of a series of articles adapted from a new book, Long Term Conditions: a Manual for General Practice Nurses, we look at the basis for all interactions in general practice, the consultation:

‘They may forget what you said, but they will never forget how you made them feel.’ ¹

INTERPERSONAL SKILLS

Introductions

How best to start? Dr Kate Granger was frustrated by the number of hospital staff who failed to introduce themselves when she was having treatment for cancer,² so she started a campaign called ‘Hello, my name is…’

We should all introduce ourselves with our name and role. You can invite the patient to sit down, while smiling and making eye contact, but a wise clinician will never say, ‘How are you?’ as a greeting.

This can be a good moment to find out what the patient likes to be called. One method is to say, ‘Hello, my name is Jo, I am one of the nurses here. May I just check your name please?’ The answer might be ‘Mrs Waite’ and then you know how she wishes to be addressed. Or the patient might say, ‘My name is Patience Waite, but everyone calls me Pat.’

To help staff say the correct name in future, it is useful to insert the patient’s preferred name when typing free text, for example ‘Pat can walk faster now she has started salbutamol.’ Your computer system may let you enter the preferred name onto the patient’s registration details.

The term ‘triadic consultation’ means there are three people taking part in a consultation: you, the patient and a third person, who may be an interpreter, patient, relative or carer. You will need to check the name and role of this person. At the start, it helps if you arrange the seating to enable direct eye contact with the patient, with the other person equally involved or kept peripheral. When a parent is present, you can try speaking to the child first and then involve the parent. With an interpreter, try to keep eye contact with the patient throughout.

Agreeing an agenda

The next stage in the consultation is to agree an agenda, led by the patient. You could say something like ‘What has brought you to see me today?’ Some clinicians just say ‘Now…’ and wait. If you know the reason for the appointment, you could acknowledge that and then ask, ‘Where would you like to start?’

To confirm the agenda, you could say ‘It sounds like we should talk about your breathing today, and I know you are due for a thyroid check. Shall we deal with both of those over the next fifteen minutes? Is there anything else you feel is important to discuss today?’

Then you might say, ‘What has been happening recently with your asthma?’ This is called an open directive question, as it does not restrict the patient to a yes/no answer, but focuses their attention on the topic. A closed question (‘Has your asthma been OK recently?’) tends to shut down good communication, one problem being that people may prefer to answer a closed question with ‘yes’ rather than ‘no’.

Active listening

Next, you stop talking and you wait. Silence will allow the person to speak about difficult emotions, worries or queries. You will probably encourage the patient by nodding or smiling, but you must not interrupt.

This is the ‘golden minute’ of the consultation, the key to patient-centred consulting, where the patient’s needs take precedence over yours. Hardly anyone will talk for longer than one minute, if given freedom to express their concerns without interruption, and you will gain a clear picture of the patient’s needs.

You will have the opportunity to listen attentively, which is necessary to identify the ideas, concerns and expectations (ICE) of the person alongside you.³ In this way, you will come to understand and respect them as an individual, which is the basis of good general practice.

If the patient starts to talk about other matters, you can gently draw them back to the agreed agenda. All the while, you will be gaining information about their way of life, the psychosocial context, which has a profound effect upon human health.

DATA GATHERING

Patients who go to hospital are bombarded with questions about their presenting complaint, past medical history, drugs, allergies, family history, and social history. We can work much faster in general practice, because most of this information is already summarised in the medical record. You need to glance through the history before the patient enters the room and it is sometimes worth flagging up to the patient that you have done so: ‘I have looked at your records and I know you had a very difficult time in hospital last month.’

With background knowledge, the computer will intrude less into the consultation and you can give full attention to the reason the patient has attended today. The computer will seem less alienating (and you will appear more engaged) if the patient can look at the screen with you.

A good nurse is interested in how people tick, and wants to understand their experience. You must consciously make an effort to discover the patient’s ideas, concerns and expectations (ICE). Having obtained this information, you will then be well placed to treat the patient as an individual and address their particular concerns.

For example, you may attribute a patient’s fatigue to her poor diabetic control. It is helpful to ask directly, ‘What are your thoughts about being so tired?’ because patients often need permission to speak of their thoughts and deepest worries. The patient may know her fatigue is connected with on-going domestic turmoil, or she may fear it is the first sign of an undiagnosed cancer. Overwhelmed by troubles at home or expecting tests for cancer, she could dismiss your suggestion to increase the metformin dose.

Leading questions should be avoided when possible. For example, you could ask ‘Does walking make your pain worse?’ which invites a yes/no answer. It is better to say, ‘Does anything make the pain worse?’

Verbal and non-verbal cues

As you develop the skills of concentration and active listening, you will learn to identify and respond to cues. Cues are hints of important underlying emotions or concerns. They can be verbal cues, such as ‘I know about diabetes because of my mother’ or they can be non-verbal, perhaps a sigh, a hesitation or just a downward glance.

It is important to acknowledge, reflect and clarify these cues, to help you and your patient work together towards greater understanding of their health problem. You might say, ‘You mentioned that you know about diabetes because of your mother…’ and then pause for the person to reply. Or ‘You looked thoughtful when you were telling me about…’

When patients are obviously upset, a good way to show empathy is to name the emotion and then clearly demonstrate that you have understood what they are saying. ‘I can see you are angry about the situation, and no wonder. It sounds like a dreadful experience’. This technique shows you have heard and will often allow the consultation to progress.

Cues can be overt or subtle and are sometimes best observed on a video recording. If you work in a training practice, the trainer might help you make a video of some consultations, with the patients’ consent, of course. Many clinicians feel anxious about video analysis of their work, but GP trainers have expertise in giving constructive feedback and the process can be an excellent way to hone and develop consulting skills.

Difficult issues

Sometimes patients need to talk about very sensitive and personal issues, examples being domestic violence, sexual matters and death.^4,5 A nurse who knows the patient well may be the best person to initiate the discussion, but the consultation may be challenging.

How best to start a conversation about domestic violence? You will need to see the victim alone. You might say, ‘Violence at home can have a big impact on health. Does your partner ever treat you badly?’ The term ‘partner’ is gender neutral. You need information about local resources for people suffering domestic violence and you can advise a victim to have an escape plan, with all their important documents kept in one envelope.

The Sexual Respect Toolkit has guidance to help us talk about sex with our patients. If necessary, the nurse can then give information about local organisations that provide psychosexual counselling, such as Relate.

When patients are approaching the end of life, you might say, ‘Have you thought about what sort of treatment you would want, if your health gets worse?’ and ‘Does someone help you with decisions like that?’ The answers should be entered onto the medical record and/or the advance care plan.

The nurse should remember that patients with long term physical conditions will often suffer from anxiety or depression. Later in this series we will be looking in more detail at mental health, with suggestions about suitable questioning.

Data collection includes sensitive enquiry about risky activities, with a view to risk modification for the future. There is further information about health promotion in the next chapter.

Very occasionally, a patient’s behaviour may be unpredictable, making you feel uneasy. Every consulting room should be arranged so the clinician can easily escape, past the patient and out of the door. There should also be a panic button, on your desk or computer screen, so you can call for help in the event of any emergency. You can test the system when new staff have their induction.

Telephone consultations have particular challenges (Box 2).

CLINICAL MANAGEMENT

In patient-centred consulting, we try to negotiate a shared management plan. This requires understanding from both parties.

The nurse must speak in plain English, using words the patient will understand. Less is more. Choose a few words wisely. There is no point in speaking at length, as the patient will forget most of what you say, you will get tired and your appointments will over-run.

Aim to back up your words with leaflets or websites, such as the NHS Choices website which lists foreign language resources on its home page, or Patient UK As you read these resources yourself, you will gradually become better at explaining health problems in simple language.

If you have concerns about a patient’s ability to read, you can ask, ‘How would you feel about written information?’ This is a relatively non-stigmatising enquiry, as it allows for difficulties with language and eyesight, as well as learning disability or lack of education.

We used to talk about ‘compliance’ with treatment, in other words, the patients did as they were told – or so we liked to think. Now we use the word ‘concordance’ to describe an agreement between patient and clinician, regarding treatment options. We try to enter into a dialogue with the patient, rather than telling them what to do. Your patient is much more likely to follow your advice, if they understand the reason for it.

This requires the nurse to explain the options. There are always options available and the patient should be encouraged to make an informed choice. Their options will include no treatment, non-pharmacological approaches and drugs. We should take reasonable care that the patient is aware of the risks of a proposed treatment, and has information about any suitable alternatives.

The choice of treatment will depend upon the patient’s individual circumstances and how they see the situation. Sometimes a team will exclude a person from the practice’s quality indicators, having decided with the patient or their family that certain management options are not appropriate. This often happens as a patient approaches the end of life, and requires an explanation on their medical record, for example, ‘excluded from hypertension indicators because of frailty, falls and multiple co-morbidities’.

Patients on repeat prescriptions need regular review of their medication, by a trained person. Sometimes the review will involve stopping medication. This is often appropriate in elderly patients with many long term conditions, who can accumulate a multitude of medicines as the years go by. Their metabolism will have changed as they age and the drugs can interact with each other. If you notice that such a patient is overdue for a medication review, it is worth asking a prescriber to check if all the medicines are still necessary.

It is very difficult to take medicines exactly as prescribed. If a patient is muddled, the prescriber could add explanatory labels on their prescriptions, e.g. ‘take one tablet each morning for blood pressure’. You can also suggest the patient asks their pharmacist for a Medicines Check Up. Patients or relatives can buy pillbox organisers and pharmacists will sometimes dispense in blister packs. However, none of these work unless the patient agrees they need the tablets.

FINISHING THE CONSULTATION

We have considered how to say hello. You have helped the patient make an informed decision about the management options. How best to say goodbye? A summary of the discussion can be useful, to close the consultation and check you are in agreement.

Before the patient leaves, ensure you have dealt with ‘safety netting’ and the follow-up arrangements. For safety netting, you might say, ‘If “this” happens, you should call me within a few days, if “that” happens you should dial 999 and go straight to hospital’. For serious health conditions, check that the patient understands, perhaps by asking them to repeat back what you said.

Follow-up arrangements might be, ‘How about you see me next week if you are not improving? If things are going well, what about seeing me in six weeks?’ Note this is again a shared management plan, an invitation rather than an instruction.

Sometimes you will need to signal to the patient that time is up. You can say, ‘We have covered a lot today, can we leave it there?’ Or if time has run out, you can acknowledge it. ‘Our 15 minutes has come to an end. I know there are still some issues we have not had a chance to cover. I will list them in your notes, I wonder if we could look at them when we meet next week?’ This approach acknowledges the time pressure, but remains patient centred and respectful.

Returning to the quote at the beginning of this article, do you think your patient feels better, having seen you? GP trainees use anonymised Patient Satisfaction Questionnaires to assess the quality of their consultations and you may wish to do the same.

What about the nurse, how are you feeling? Roger Neighbour7 has written of the importance of ‘housekeeping’ at the end of a consultation. This is the moment where you sit back and take stock, reflect upon the last encounter or make a note of something to learn. It might be a pause for coffee and a chat with other members of the team. We all need these precious moments in the day, for our own wellbeing in a job that requires us to give so much.

CONSULTATION MODELS

The ideas in this chapter are based upon consultation models described in the scientific literature. We are fortunate in British general practice to have various consultation models, built upon a bedrock of thoughtful academic analysis. We have:

• The four areas of a typical consultation described by Stott and Davis⁶
• The five checkpoints of Roger Neighbour⁷
• The six phases identified by Byrne and Long⁸
• The seven tasks of David Pendleton⁹

All of these consultation models merit further study. For training purposes, the Royal College of GPs has synthesised the concepts into three categories: interpersonal skills, data gathering and clinical management.¹⁰

PAUSE FOR REFLECTION

For revalidation purposes, you will need to prepare a reflective account with the theme ‘prioritise people’. You could think about your own consultation skills by reviewing a morning’s appointments. Did you manage to identify and address the ideas, concerns and expectations (ICE) of every single patient? If not, what was the reason? For a different viewpoint, you could try agenda, beliefs and choices (ABC).

Alternatively, you could reflect upon the cues you spotted in today’s consultations. Was it challenging to respond to some of the cues? Would you respond differently if a similar situation arose again?

REFERENCES

1. Richard LE. Richard Evans’ Quote Book. Salt Lake City: Publishers Press; 1971. p.244

2. Kate Granger. #hellomynameis [Internet]. [cited 2016 Jan 17]. Available from: www.hellomynameis.org.uk

3. Tate P. The Doctor’s Communication Handbook (5th edn) Oxford: Radcliffe Publishing 2003.

4. Chapple A, Prinjha S, Salisbury H. How users of indwelling urinary catheters talk about sex and sexuality: a qualitative study. The British Journal of General Practice. 2014;64(623):e364-e371. doi:10.3399/bjgp14X680149.

5. Boyd K, Murray SA. Why is talking about dying such a challenge? BMJ. 2014 Jun 6;348:g3699.

6. Stott NCH, Davis RH. The exceptional potential of each primary care consultation. B J Gen Pract, 1979; 29: 201-5

7. Neighbour R. The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style. Reading: Petroc Press; 1999: 68-92

8. Byrne PS, Long BEL. Doctors Talking to Patients. London: Royal College of General Practitioners; 1984

9. Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: an Approach to Learning and Teaching. Oxford: Oxford University Press; 1984

10. Royal College of General Practitioners. MRCGP Clinical Skills Assessment Candidate Feedback