Consultation Skills - Evaluating your consultations

Analysing your patterns of behaviour can identify strengths and weaknesses, writes Dr Peter Tate.

Mapping consultations can help you evaluate your consultation style (Photograph: J Varney)
Mapping consultations can help you evaluate your consultation style (Photograph: J Varney)

So much has been written on this topic that perhaps it is time to get back to the bedrock. I know there are consultations we all find challenging and sometimes our enthusiasm diminishes, for all sorts of reasons, but the most common reason is the feeling that we are just not getting through.

Map your behaviour
When this time comes, there is something you can do - it will take a little effort, as you have to watch yourself consulting. Get out the consent forms, fix up the video recorder and record for a couple of days. Just keep to the new presentations this time - about 10 if possible.

What you are going to look at are your beginnings, your middles and your ends. Next you are going to map these behaviours. The graphs you draw will show you quite unequivocally your regular patterns of behaviour and within 10 maps or so you will have a histogram of your consulting style.

Armed with that information you will be able to see at a glance your strengths and weaknesses.

What to map?
Again, going back to the basics, the map could include the following areas:

  • Presenting problem
  • Ideas
  • Concerns
  • Expectations
  • Clinical decision making (including examination)
  • Sharing options
  • Explaining
  • Sharing understanding
  • Managing (including prescribing)
  • Checking understanding

This can be done with old-fashioned acetate but it is much more fun and graphic on a computer or a flat screen tablet.

How to map
To use the map, watch a consultation and enter a symbol every time you feel a significant exchange occurs. Sometimes you will feel that two events occur at once, such as decision making and option sharing, in which case you should put a mark in both areas.

This is not a precise tool, but it will leave you with a reasonable record of the sequence of events. If two of you complete a map of the same consultation (for example, trainer and registrar) the differences can highlight different perceptions and form the basis for significant discussion and learning.

Many consultations contain multiple problem presentations. To distinguish these on the same map, you can use other symbols. After completion of the consultation, join all the marks and other symbols together sequentially.

With a little practice, you can map the consultations of colleagues while their consultations are in progress. This gives you a permanent record without technology and stops a lot of arguments about what did and did not occur.

How to use the map
Now you have your record, what use can you make of it? Firstly, you must be aware of what the map does not do very well. Treat it like a road map; it will tell you the places you visited and the ones you did not, but it will not tell you what they were like - you have to make that quality judgment.

It may show you spending 10 minutes on examining your patient, but you will have to judge how appropriate and efficient that examination was.

The map only tells you that you did it, not how well you did it.

However, because of its sequential nature, a series of maps of you consulting will be revealing. The example (click here to see example) shows a complete absence of sharing understanding and checking understanding, suggesting a controlling style of behaviour with lack of patient involvement. This is the time to layer sequential maps to see if there are recognisable patterns.

For example, it may perhaps demonstrate the 'tomorrow never comes' scenario. This is characterised by the response to a query as to why a particular task was not done at that consultation: 'Oh yes, sure patients concerns are important, I was a bit rushed this time, but I will definitely ask him next time.'

However, if a look through several more maps reveals none has an entry under 'patient concerns' then you will have to face the fact that tomorrow never comes. Used in this way you can quickly spot areas of weakness.

Perhaps you find you do a lot of explaining but little sharing of understanding, that is, using your patient's belief system to produce a bespoke explanation. You may find this is because you do little exploration of their beliefs in the first place. Many of you will find you do little checking of understanding.

You may have a series of consultations that are hard to map because the patient keeps pulling you back to the presenting problem - this is a common sign of dysfunction in the consultation, and it usually means you are pursuing your agenda to the exclusion of your patient's agenda, who keeps trying to pull you back to what worries them.

Mapping is an easy but underused tool that will quickly show you your own style and allow you to evaluate that style and take steps to remedy the weaknesses you identify.

  • Dr Tate is a retired GP in Corfe Castle, Dorset, and author of The Doctor's Communication Handbook and the Effective Consulting DVD. To order his latest educational DVD, called Interpersonal Skills for the CSA, for £27.99 including postage and packing, at gponline.com/consulting

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