Consultation Skills – Three Golden Rules

My consultation skills are gradually improving.  I’m currently seeing a patient every 10-12.5 minutes.  By the time I finish my training next August I need to be consistently at 10 minutes per consultation.

A couple of years ago when I started my GP training I really had no clue how GPs could see patients so quickly.  In the hospital doctors get more like 30-40 minutes to clerk a patient when they arrive to the ward.

I’ve found a few tricks that are really helpful for any budding GPs out there.  It’s also very handy for hospital doctors to know this stuff as well.  GPs have a very patient-centric approach in the way that they provide care.  Most patients genuinely appreciate this approach as it takes into consideration the patients social issues, their health beliefs and ultimately treats them like a human being.  I have often heard hospital doctors get into confrontations with patients because they have not taken a patient centred approach.  A lot of altercations could be avoided if more doctors would take the rules below into account.

So here are the three golden rules to get a super quick focused history:

Tip One: Have a Structure

This doesn’t mean the usual history taking that we get taught in medical school.  In medical school we get taught to take presenting complaint, history of presenting complaint etc etc.

In the real world you don’t really need to do it like this.  In the real world structure your consultation like this:

  • Golden minute

Let the patient talk and get their thoughts off of their chest.  Really listen to this part. The patient is literally telling you what’s wrong.  Try not to speak. Ask open ended questions.  So for example if they presented with pain then ask them to tell you more about the pain rather than asking specific  closed questions.  You’ll be surprised at what they tell you.

  • Ask them what they’re worried about if anything and what they want you to do.

This isn’t so that you just do what they tell you to do, but because then you can reconcile your decision making with their expectations and health beliefs.  This is a very common reason why patients get upset and angry.  It’s not because we don’t listen to them, but because we haven’t heard what they are trying to tell us.

  • Ask specific questions

This is the part where you can go more into doctor mode and ask those questions that we have memorised over the years.  Make sure you signpost that you are going to ask some specific questions to the patient: “I want to ask you some more specific questions about this pain you’ve been having.”

  • Red flags

Now ask red flags.  “Have you had any bleeding from your back passage?”.

  • Ask about PSO (more on this below)
  • Examine the patient if needed
  • Bring it all together and explain the diagnosis to the patient and give a management plan.

In this part you should also take into account the patients expectations and health beliefs.  For example:  “It seems that this tummy pain you’ve been having may be something quite serious.  Because you have pain in that part of your tummy, I think you might have appendicitis.  This may be an emergency, so I don’t think just doing some blood tests like you mentioned would be the right thing to do right now….”

Even if you panic and are not sure what the patient is talking about.  If you fall back to this structure, then 99% of the time you’ll have a smooth consultation which shouldn’t take longer than 10 minutes.  Always fall back to this model if you’re not sure where the consultation is going or you’re taking too long.

Tip Two: Pick Up On Cues

This is an incredibly important trick.  I’ve always wondered how the more senior doctors used to get such a good history from the patient.  Often when I would be on the post take ward round the patient would give a completely different history and story to the consultant.  I couldn’t figure it out and it used to drive me crazy.

The problem is that when you’re more junior, you have these pathologies in mind and then you try and fit said patients into those categories.  For example if someone has abdominal pain you start asking about SOCRATES.  However, the more experienced doctor, rather than trying to fit the patient into a pattern will listen to the patient.  They’ll pick up on cues that the patient mentioned and then ask a relevant question.  If you do it this way then all of the information you would have gotten from things like SOCRATES will have come out automatically and in a more natural manner.

A typical conversation doing things this way, goes like this:

Patient: “I’ve been having this tummy pain for the last couple of days.  I thought it was some indigestion at first, but it seems to be getting worse now and I’m a little worried about what it might be.”

Doctor: “You said you’re a little concerned (picking up on the cue).  Can you tell me what exactly you’re worried about?”

Patient: “I’m worried about my appendix.  My brother had a similar thing.  The pain kind of started in the middle of my tummy, now it’s like a sharp pain, moving down here (points to RIF).  It doesn’t seem to be getting better even with paracetamol, so I’m quite worried”

In this example you’ve got most of SOCRATES already.  The patient has already given you loads of info.  You can then signpost and say you’re going to ask some specific questions such as whether it hurts when they pass water, if there’s any bleeding from anywhere etc.  Your whole history taking will take less than five minutes if you do it this way.

Asking a well placed, relevant question which picks up on a cue will give you an explosion of medically relevant information.

Tip 3: Ask About PSO

PSO stands for psycho-social-occupational history.  Until I started GP training, I don’t think I really appreciated how important this aspect of history taking really was.  It’s the sign of an accomplished doctor and consulter.

This is the number one reason why so many hospital doctors get into fights with their patients.  It’s also one of the main reasons patients hate going to the hospital.

If for example a patient arrives on MAU and they have something like hypercalcaemia, but is otherwise fine in themselves it may come as a shock to them that they’ll have to stay in the hospital for IV’s.

To avoid a misunderstanding, during your history taking you need to ask about the patient as a whole.  Whose at home?  What do you do?  Do you smoke?  Do you drink?  Is anyone with you?  This takes less than a minute to ask most of the time.  If the patient says something like: “I live alone.  I’m a taxi driver and need to be out of here by 8pm for my shift…”, then you can incorporate this into your management plan:  “You have a very high calcium level.  I know that you feel fine and that you have your shift soon.  But, if we don’t get your levels corrected then it can lead to etc etc.”

I can’t stress how many arguments and misunderstandings with patients can be avoided if this approach is taken.  Hospital medicine is very doctor-centric in this manner.  If the patient goes to the hospital with something like the above and says: “No, I have to leave because I have my shift.  I’m self employed!”, then usually the senior doctor says something along the lines of either “Let me speak to him/her” or “Does he/she have capacity to leave?  If so then let them go after they’ve signed the disclaimer.”  This is not good medicine.

If you incorporate all of the above tips into your history taking then I can guarantee you’ll be a better doctor for it and your patients will love you to boot!  Happy consulting!

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