Consulting skills: Meaningful consultations

Professor Rodger Charlton writes about getting the balance right in a 10-minute consultation.

Sometimes a patient will say: 'Sorry I have wasted your time.' I always reply: 'Far from it.' It may just have been reassurance, but to the patient, it was important and worrying, so I feel it is rewarding that I have been able to help.

The 10-minute consultation

When I started as a GP, I ran six-minute consultations and used to see 20 or more patients in a surgery.

I feel now that I could not see so many patients at such speed and I certainly could not attempt to meet their needs. Even now, 10 minutes is rarely long enough.

Talking to other GPs, I find that some build in 'catch-up' slots, because they know they will over-run, and some have further increased their consultation time.

However, despite our aspirations to provide a more holistic consultation through increased time, the competing demands on our time are multiple, for example, telephone and email consultations.

Perhaps an ideal in the future will be 15 or 20 minutes, as it is realised that we are the new consultant generalist physicians.

When I worked in New Zealand 20 years ago, 15 minutes was the normal consultation length. These days, GP shortages and difficulty with recruitment mean most of my colleagues are having to see huge numbers of patients and cannot aspire to this.

Listening

Some time ago, I saw a patient who was somewhat disgruntled with other doctors they had seen. I spent some time with them and at the end, they said they felt better just for being listened to. When we are rushed and busy, this is not easy, but it is what patients want and if I were in their situation, I would want that too.

Many of our patients have complex lives and stories, which academics call patient narratives. They present with multiple symptoms of perhaps tiredness, aching all over, vague headaches and much more. Our job is to listen and try to make sense of what is sometimes referred to as undifferentiated illness, to discover whether there is any underlying disease. This requires great skill and GPs should take pride in what can be challenging and very stressful at times, in a sea of diagnostic uncertainty.

People in the consultation

About half of GP practices in the UK are involved in teaching medical students, foundation year doctors, GP registrars, or all of these.

When a student sits in on a consultation, they are the fourth person in the room.

The third 'person' is the computer, to which we pay a lot of attention and without which we cannot conduct a consultation, work out our appointments, see records and issue a prescription or fit note.

These consultations tend to be longer - we are keen to 'perform' even better when we are being watched, while the patient has more time to say what is wrong and to obtain two opinions.

Bereavement

It could be argued this is not a medical problem. Research would suggest that bereaved spouses have a greater incidence of morbidity, such as depression, and mortality.

In an ideal world, the GP might make contact with a patient after a death, or send a letter or card offering condolences and a meeting in future if they wish.

It could be that the GP was present at the death or shortly afterwards to confirm and certify death.

In my experience, most patients greatly appreciate this contact and even months or years later, say how helpful it was, particularly with providing an 'open door' in the future to talk about their feelings or ask questions about the person's illness that they did not understand and are now perhaps making them feel guilty.

Compassion

At the RCGP conference in October, Dr Alys Cole-King said how important it was to acknowledge patients in what may seem minor issues. This could simply be saying hello to a patient who passes you in the corridor, or in the consultation, when they tell you about a domestic problem that is troubling them.

Patients appreciate recognition from 'their' doctor and a momentary compassionate comment.

Please don't ask me to define compassion. It is indefinable, but the pace and pressure we are under means it is often squeezed out. Perhaps it is a moment of kindness or caring and, dare I say it, 'empathy in action'. However you define it, it is a huge challenge for us to provide meaningful consultations.

  • Professor Charlton is a GP in Hampton-in-Arden and director of undergraduate primary care education, School of Medicine, University of Nottingham

Resource

Connecting with People: www.connectingwithpeople.org

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